Firefighters’ Physical Activity: Relation to

Fitness and Cardiovascular Disease Risk

GERARDO DURAND1,2, ANTONIOS J. TSISMENAKIS1,2,3, SARA A. JAHNKE4, DOROTHEE M. BAUR1,2,
COSTAS A. CHRISTOPHI1,5, and STEFANOS N. KALES1,2
1
Department of Environmental Health, Environmental & Occupational Medicine and Epidemiology, Harvard School of Public
Health, Boston, MA; 2Employee & Industrial Medicine, Cambridge Health Alliance, Cambridge, MA; 3Boston University
School of Medicine, Boston, MA; 4The Institute for Biobehavioral Health Research, National Development and Research
Institutes, Leawood, KS; and 5Cyprus International Institute for Environmental and Public Health in association with Harvard
School of Public Health, Cyprus University of Technology, Limassol, CYPRUS

ABSTRACT
DURAND, G., A. J. TSISMENAKIS, S. A. JAHNKE, D. M. BAUR, C. A. CHRISTOPHI, and S. N. KALES. Firefighters’ Physical
Activity: Relation to Fitness and Cardiovascular Disease Risk. Med. Sci. Sports Exerc., Vol. 43, No. 9, pp. 1752–1759, 2011. Purpose:
Cardiovascular disease (CVD) accounts for 44% of on-duty deaths among US firefighters with a markedly higher event risk during
strenuous duties compared with nonemergencies. Sedentary persons are most susceptible to such CVD ‘‘event-triggering’’ due to
irregular bouts of vigorous physical activity (PA). Conversely, regular PA and increased levels of cardiorespiratory fitness (CRF) protect
against CVD triggering. Therefore, the present study evaluates PA measures in structural firefighters and their relationship to CRF and
CVD risk factors. Methods: Cross-sectional cohort study of 527 Midwestern career firefighters. PA frequency, duration, and intensity
measures from a questionnaire along with total weekly aerobic exercise were analyzed. CRF was measured by maximal exercise
tolerance testing. CVD risk parameters included body composition, blood pressure, and metabolic profiles. Group differences were
compared using general linear models. Results: Measures of increasing frequency, duration, intensity of PA, and total weekly exercise
(min) were significantly associated with higher CRF (P G 0.001) after adjustment for age, body mass index (BMI), and smoking status.
After multivariate adjustment, increasing PA frequency was significantly associated with reduced total cholesterol–HDL ratio, triglyc-
erides, and glucose, as well as HDL increments. Increasing BMI category was associated with significant decrements in CRF and
unfavorable dose–response trends in CVD risk factors (P G 0.001), even for those reporting very frequent, sustained, and intense PA.
Conclusions: Increasing PA has beneficial independent effects on CRF, and PA frequency has similar favorable effects on CVD risk
profiles. Whereas PA was beneficial regardless of BMI category, increasing BMI category had strong independent unfavorable effects.
PA should be strongly encouraged for all firefighters with the highest priority given to PA frequency, followed by PA duration and
intensity. Key Words: EXERCISE, METS, OCCUPATIONAL, METABOLIC, EPIDEMIOLOGY

I
t is well known that firefighters encounter many haz-
ardous occupational conditions. In particular, strenuous
duties expose firefighters to high levels of stress and
physical demands. As a result, strenuous emergency duties
have been associated with markedly higher risks of car-
diovascular events that lead to death or disability compared
with nonemergency duty (13,17,18). These data are in
agreement with studies from the general population finding
that, among unconditioned persons, stressful situations
resulting in sympathetic and cardiovascular activation such
APPLIED SCIENCES
as vigorous exercise and snow shoveling, episodes of anger,
and even watching major sports matches can ‘‘trigger’’ acute
heart disease events (4,23,33).
Accordingly, maintaining and improving the cardiores-
piratory fitness (CRF) of firefighters by increasing their
physical activity (PA) is a major priority for the US fire
service (15,25). This is especially the case because car-
diovascular disease (CVD) has accounted for 44% of
roughly 100 annual on-duty deaths among firefighters
between 1995 and 2004 (9). Moreover, 765 nonfatal on-duty

cardiovascular events were reported in 2005 (20). Thus, the

combination of fatal and nonfatal on-duty cardiovascular
Address for correspondence: Stefanos N. Kales, M.D., M.P.H., Employee & events affects close to 1 in 1000 US firefighters each year.
Industrial Medicine, The Cambridge Health Alliance, 1493 Cambridge St.,
Macht Bldg., Suite 427, Cambridge, MA 02139; E-mail: skales@challiance. Finally, CVD also results in many other off-duty events and
org; skales@hsph.harvard.edu. disability retirements (13).
Submitted for publication September 2010. Although it is universally accepted by fire service orga-
Accepted for publication February 2011. nizations and fire department physicians that firefighters
0195-9131/11/4309-1752/0 should achieve and maintain adequate levels of CRF, there is
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ less consensus as to the minimum aerobic capacity required
Copyright Ó 2011 by the American College of Sports Medicine for the safe performance of structural firefighting. While
DOI: 10.1249/MSS.0b013e318215cf25 on-duty, structural firefighters often have to wear 50 lb of

1752

Copyright © 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
personal protective equipment, carry between 20 and 40 lb
of tools, climb ladders, advance heavy water-filled hoses,
occasionally drag or carry victims, and perform other
heavy labor. These activities have been estimated to require
a maximal oxygen consumption of Q44 mLIkgj1Iminj1 or
12.5 METs (11), which, in energy expenditure terms, is
comparable to activities such as running at 7.5 milesIhj1
(8 minImilej1) or vigorous cross-country skiing (1). Thus, the
National Fire Protection Association has suggested 12 METs
(about 42 mLIkgj1Iminj1 V̇O2) as the minimum exercise
capacity required for the safe performance of firefighting
(24). However, the National Fire Protection Association is
not a governing body and can only make recommendations.
Each department decides on issues of exercise, fitness, and
health screening individually.
The physical demands of the job, elevated on-duty CVD
risks, and the steadily increasing prevalence of obesity
among firefighters have led to growing concerns regarding
the physical fitness of US firefighters. Several representa-
tive studies have found that roughly 75% of all firefighters
are overweight, with 40% classified as obese, including
a third of new recruits (5,16,30,31). Moreover, a recent
population-based cohort study of both career and volunteer
firefighters demonstrated a prevalence of overweight and
obesity exceeding that of the US general population (28).
In addition, this investigation proved that the high obesity
prevalence was not due to misclassification of numerous
highly muscular firefighters. Contrary to common wisdom
in the fire service, Poston et al. (28) found that obesity in
the population-based firefighter cohort was even more prev-
alent when assessed by body fat rather than body mass in-
dex (BMI) and that misclassifying muscular firefighters as
obese by using BMI occurred very infrequently.
Inadequate exercise has been hypothesized as a major
contributing factor to the current situation. Infrequent PA
and inadequate amounts of PA are considered commonplace
in the fire service. Structural firefighters’ work shifts often
involve long sedentary periods. The majority of US fire
departments do not mandate exercise, lack regular exercise
regimens, and do not require the maintenance of discrete
physical fitness parameters after hire. Furthermore, discre-
tionary time for exercise may be largely consumed by
overtime work and second jobs. Poston et al. (28) estimated
maximal oxygen consumption (V̇O2max) using PA self-
reports reflecting the past 30 d along with BMI, age, and
gender and found that the majority of firefighters likely had
substandard fitness. However, the study design did not allow
them to corroborate these estimates with an exercise test to
measure CRF. Thus, few, if any, representative studies have
systematically examined the exercise habits of large fire-
fighter populations and their relationship to CVD risk and
CRF as measured by a maximal exercise test.
On the other hand, the benefits of increasing PA have
been demonstrated in the general population. For exam-
ple, the Finnish twin cohort study showed that aerobically
conditioned exercisers and even occasional exercisers had
PHYSICAL ACTIVITY IN FIREFIGHTERS
Copyright © 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
decreased risk of all-cause mortality and coronary heart
disease compared with those who were sedentary (19,21).
Hu et al. (14) found that PA reduces the risk of cardiovas-
cular mortality in both obese and nonobese individuals. In
addition to its beneficial effects on CRF, regularly practiced,
frequent PA of sufficient duration can promote weight loss
and prevent weight gain (2). Moreover, PA independently
ameliorates multiple cardiovascular risk factors (10).
PA can be defined and quantified in several ways. To
assess energy expenditure, three PA dimensions are usu-
ally considered: (a) frequency—‘‘the number of events of
physical activity during a specific period,’’ (b) duration—
‘‘time of participation in a single bout of activity,’’ and (c)
intensity—‘‘physiological effort associated with participat-
ing in a specific type of physical activity’’ (32).
In the present study, we attempted to determine the most
beneficial dimension of PA among structural firefighters:
weekly frequency and session duration or session intensity,
specifically focusing on aerobic exercise activity and each
dimension’s correlation with objectively measured CRF and
CVD risk factors.
METHODS
The study sample was obtained from the ongoing cohort:
‘‘Predicting Cardiovascular Risk and Fitness in Firefighters’’
(US Department of Homeland Security Award No. EMW-
2006-FP-01493; S.N. Kales, HSPH). The participants were
structural firefighters recruited from 10 career fire depart-
ments located in the states of Kansas and Missouri. All
participants were at least 18 yr, had no restrictions on duty,
and performed a maximal exercise treadmill test (ETT) as
part of a periodic fire department medical surveillance ex-
amination. Firefighters taking the exercise test for an exit
examination, the evaluation of symptoms, or for retirement/
disability evaluation were excluded from enrollment.
Institutional review board approval was granted by the
Harvard School of Public Health Human Subjects Commit-
tee and local institutional review boards as appropriate. All
participants provided informed consent and then completed
in person the same written health and lifestyle questionnaire
in addition to undergoing their fire department’s standard
medical examination. In this cross-sectional study, we ana-
lyzed data from 527 male career firefighters who had com-
pleted PA self-reports and had available ETT and CVD risk
APPLIED SCIENCES
factor data.
ASSESSMENT OF PHYSICAL ACTIVITY
Self-reports of PA were extracted from health and life-
style questionnaire responses. Firefighters were given stan-
dardized written instructions to complete the multiple-choice
survey regarding eating, health, exercise, sleep, and work
habits as honestly and as best as they could. They were
also informed that the completed questionnaires would
be confidential and would not become part of their fire
Medicine & Science in Sports & Exercised 1753
 TABLE 1. Exercise activity questionnaire and frequency of responses.
Frequency (d)
Most weeks, I exerciseI(include home/work/gym and elsewhere).
e1
2–4
Q5
Duration (min)
Most times that I do cardio or aerobic exercise (e.g., jogging,
brisk walking, bike, treadmill, etc.), I do an average ofIeach session.
G15
15–30
30–45
945
Intensity
Most times that I exercise, I sweatIon average each session.
Do not exercise too often
Light sweat
Moderate sweat
Heavy sweat
Total weekly aerobic exercise (minIwkj1)
0–45
46–90
91–150
9150
department or medical record. To assess PA, we analyzed
the answers to three selected multiple-choice questions
about involvement in sports and exercise activities from the
lifestyle questionnaire. Each of the three questions repre-
sented a different PA dimension (32): 1) frequency—‘‘Most
weeks, I exerciseI(include home/work/gym and else-
where)’’; 2) duration—‘‘Most times that I do cardio or aero-
bic exercise (e.g., jogging, brisk walking, bike, treadmill), I
do an average ofIeach session’’; and 3) intensity—‘‘Most
times that I exercise, I sweatIon average each session.’’ To
increase the power of the analysis, the original six response
choices for frequency and duration were grouped into three
and four alternatives, respectively. The questions, response
alternatives, and the respective frequency of responses are
shown in Table 1.
In addition, a new variable was calculated to evaluate the
combined effects of PA frequency and PA session duration
as total weekly aerobic exercise. Each of the six original
alternatives in the frequency and duration dimension ques-
tions received a numerical value equivalent to the middle
point of the range of each response choice. Thus, a value of
2.5 times per week was assigned to the frequency response
n (%) of 2–3 times per week, 3.5 for 3–4 times per week, and so
on. The same methodology was applied to the duration
92 (17.5)
responses: 22.5 min was assigned for 15–30 min, 37.5 min
317 (60.4) for durations of 30–45 min, and so on. Subsequently, the
116 (22.1) resulting frequency and duration values were multiplied to
estimate total weekly exercise in minutes per week.
For the present study, we did not consider other PA
70 (13.3)
226 (43.1) domains such as occupational PA, PA during transportation
157 (29.9) and household, or domestic PA if participants did not clas-
72 (13.7)
sify these as exercise in response to the questionnaire.
21 (4.0) Outcome Measures
94 (17.9)
295 (56.3) Assessment of CRF. CRF was determined from
114 (21.8)
symptom-limited, maximal treadmill exercise testing with
124 (23.7) ECG monitoring and estimation of oxygen consumption
154 (29.4)
139 (26.6)
(METs) after the Bruce or modified Bruce protocols. The
106 (20.3) participants were encouraged to continue exercise until vo-
litional exhaustion, even after exceeding 85% of their max-
imum predicted HR (220 j age). On average, the cohort
achieved 99.7% T 6.5% of maximal age-predicted HR on
these tests. During the exercise test, total treadmill time in
seconds (ETTT), maximum METs achieved (maxMETs), and
HR recovery at 1 min (HRR) were recorded. In addition, an
‘‘autonomic index’’ was calculated by dividing the resting HR
(RHR) (taken at rest preceding the physical examination) by
the HRR as an assessment of integrated autonomic nervous
system function (RHR/HRR index) (22).
Assessment of cardiovascular risk factors. Height
was measured in a standing position with a clinic stadi-
ometer. Body weight was measured with bare feet and in
light clothes on a calibrated scale. BMI was defined as weight
in kilograms divided by the square of height in meters. The
RHR and blood pressure were measured before the physical
examination with the subject in the seated position and using
an appropriately sized cuff for the blood pressure.
Venous blood samples were analyzed for total cholesterol
(TC), HDL, LDL, triglycerides (TG), glucose, and high-
sensitivity C-reactive protein (hs-CRP) using standardized
methods.

TABLE 2. Association between physical exercise frequency (mean T SD) and main outcomes.
e1 d 2–4 d Q5 d Unadjusted P Adjusted P a
CRF
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MaxMETs 11.8 T 1.7 12.7 T 1.6 13.5 T 1.2 G0.001 G0.001

ETTT (s) 588.1 T 94.6 646.1 T 100.1 697.5 T 90.7 G0.001 G0.001
HRR (bpm) 31.6 T 13.3 32.1 T 13.1 35.4 T 14.7 0.05 0.3
RHR/HRR index 3.3 T 1.9 3.3 T 2.8 2.9 T 2.4 0.3 0.5
Cardiovascular risk factors
SBP (mm Hg) 121.7 T 11.3 123.5 T 13.1 121.1 T 11.3 0.2 0.1
DBP (mm Hg) 80.3 T 7.4 80.4 T 8.1 78.5 T 7.7 0.07 0.3
TC (mgIdLj1) 195.3 T 36.2 194.0 T 38.8 183.8 T 32.6 0.03 0.2
HDL (mgIdLj1) 42.8 T 11.1 44.6 T 11.0 50.6 T 12.4 G0.001 0.001
LDL (mgIdLj1) 120.7 T 34.3 119.6 T 31.4 112.5 T 29.5 0.09 0.4
TG (mgIdLj1) 173.9 T 138.4 159.0 T 155.0 106.9 T 60.6 G0.001 0.02
TC/HDL 4.9 T 1.5 4.6 T 1.5 3.9 T 1.2 G0.001 0.003
Glucose (mgIdLj1) 96.3 T 13.6 93.8 T 15.2 88.7 T 11.3 G0.001 0.005
hs-CRPb (mgIdLj1) 3.7 T 6.4 2.0 T 4.0 1.3 T 1.6 0.02 0.07
a
Adjusted for BMI, age and smoking status.
b
Population: e1 d (n = 44), 2–4 d (n = 128), Q5 d (n = 62).

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Copyright © 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
TABLE 3. Association between physical exercise duration per session (mean T SD) and main outcomes.
G15 min 15–30 min 30–45 min 945 min Unadjusted P Adjusted P a
CRF
MaxMETs 12.1 T 1.6 12.6 T 1.6 13.0 T 1.7 13.1 T 1.4 G0.001 G0.001
ETTT (s) 604.5 T 92.2 641.9 T 96.5 665.0 T 113.0 668.2 T 96.1 G0.001 G0.001
HRR (bpm) 31.3 T 12.6 30.4 T 12.9 35.8 T 13.7 35.3 T 14.7 G0.001 G0.001
RHR/HRR index 3.3 T 1.8 3.6 T 3.0 2.8 T 2.3 2.8 T 1.6 0.02 0.02
Cardiovascular risk factors
SBP (mm Hg) 122.5 T 12.1 122.3 T 12.7 122.4 T 12.2 125.1 T 13.4 0.4 0.2
DBP (mm Hg) 80.9 T 7.0 79.9 T 7.8 79.5 T 8.5 80.4 T 8.3 0.6 0.7
TC (mgIdLj1) 194.0 T 37.3 192.5 T 40.3 191.0 T 34.1 190.3 T 34.3 0.9 1.0
HDL (mgIdLj1) 45.0 T 11.2 44.1 T 11.3 47.3 T 12.4 46.8 T 10.9 0.05 0.09
LDL (mgIdLj1) 117.0 T 31.3 118.3 T 32.8 118.2 T 31.1 120.0 T 29.7 1.0 0.8
TG (mgIdLj1) 188.0 T 226.9 153.9 T 133.5 135.7 T 111.8 128.3 T 64.0 0.03 0.07
TC/HDL 4.6 T 1.5 4.6 T 1.6 4.3 T 1.4 4.3 T 1.3 0.1 0.2
Glucose (mgIdLj1) 95.2 T 15.7 92.9 T 12.6 92.3 T 11.7 93.7 T 22.1 0.6 0.6
hs-CRPb (mgIdLj1) 3.0 T 7.4 2.4 T 4.6 1.8 T 2.2 1.5 T 1.3 0.4 0.5
a
Adjusted for BMI, age, and smoking status.
b
Population: G15 min (n = 30), 15–30 min (n = 94), 30–45 min (n = 78), 945 min (n = 33).

Statistical Methods
Each of the PA dimensions was analyzed separately as a
categorical variable (Table 1). The outcome measures were
all continuous. Analyses were carried out using SAS 9.1.
We used the ANOVA method to assess the difference in the
mean values among three or more groups and general linear
models to examine the effect of covariates on the different
outcomes after adjusting for age, BMI, and smoking status.
In the analyses involving the total minutes of exercise per
week variable, we further adjusted for physical exercise
intensity (sweat). For statistical significance, we considered
P G 0.05 using two-tailed tests.
RESULTS
The mean T SD age of the 527 participants was 37.2 T
8.6 yr. The mean T SD BMI was 29.3 T 4.5 kgImj2. Using
the World Health Organization BMI categorization, 13.1%
(n = 69) were of normal weight, 51.2% (n = 270) were
overweight, and 35.7% (n = 188) were obese. Only 63 par-
ticipants (12.0%) reported regular smoking. Almost half
(49%) of the cohort exercised three or fewer times per
week, and only 22% exercised five or more times weekly.
Regarding total weekly aerobic exercise, 47% were esti-
mated to be exceeding 90 min of weekly of moderately
vigorous PA, whereas only 20% exceeded 150 min weekly.
The cohort’s mean T SD measured exercise tolerance was
12.7 T 1.6 METs. More than a third (37%) of the firefighters
had CRF e12 METs.
The analysis of PA frequency, duration, and intensity in
relation to the main outcomes is shown in Tables 2–4.
Among the four CRF outcome variables, ETTT and max-
METs consistently showed significant differences along
the three PA dimensions after adjusting for age, BMI, and
smoking status (P G 0.001). The dose–response patterns of
both variables as a function of BMI and each of the PA
dimensions are summarized in Figure 1, where adverse as-
sociations with increasing BMI category across all PA
dimensions for both CRF and CVD risk factors are readily
apparent. Although HRR progressively increased along
with PA frequency, the difference did not reach statistical
significance. Conversely, HRR showed statistically sig-
nificant differences along the duration (P G 0.001) and
intensity dimensions (P = 0.005) despite showing dose–
response inconsistencies within the lower range of each PA

TABLE 4. Association between physical exercise intensity (mean T SD) and main outcomes.
Do Not Exercise Often Light Sweat Moderate Sweat Heavy Sweat Unadjusted P Adjusted P a
CRF APPLIED SCIENCES
MaxMETs 11.0 T 1.3 12.6 T 1.5 12.7 T 1.6 13.0 T 1.7 G0.001 G0.001
ETTT (s) 551.9 T 81.0 638.6 T 91.9 649.8 T 98.4 666.7 T 114.4 G0.001 G0.001
HRR (bpm) 30.3 T 12.8 30.1 T 11.8 32.4 T 13.1 36.4 T 15.6 0.006 0.005
RHR/HRR index 3.4 T 2.4 3.4 T 2.0 3.3 T 2.8 2.9 T 2.3 0.4 0.4
Cardiovascular risk factors
SBP (mm Hg) 123.0 T 10.9 121.6 T 11.7 122.7 T 12.8 123.6 T 13.4 0.7 0.8
DBP (mm Hg) 82.5 T 6.8 79.7 T 7.6 79.9 T 7.7 80.0 T 9.2 0.5 0.9
TC (mgIdLj1) 197.2 T 36.5 198.1 T 43.9 190.4 T 36.0 190.8 T 34.2 0.3 0.5
HDL (mgIdLj1) 45.2 T 10.4 45.5 T 11.7 45.2 T 11.4 46.4 T 12.3 0.8 0.5
LDL (mgIdLj1) 118.7 T 37.9 120.3 T 32.8 117.8 T 31.0 117.9 T 31.2 0.9 0.9
TG (mgIdLj1) 184.1 T 148.1 170.2 T 197.0 145.4 T 128.3 140.5 T 97.7 0.3 0.2
TC/HDL 4.5 T 1.1 4.7 T 1.9 4.5 T 1.4 4.4 T 1.4 0.5 0.1
Glucose (mgIdLj1) 98.1 T 11.8 95.1 T 14.0 92.4 T 14.3 92.6 T 14.9 0.2 0.4
hs-CRPb (mgIdLj1) 1.2 T 1.1 1.9 T 3.1 2.6 T 5.2 1.5 T 1.4 0.4 0.3
a
Adjusted for BMI, age and smoking status.
b
Population: do not exercise often (n = 9), light sweat (n = 39), moderate sweat (n = 130), heavy sweat (n = 56).

PHYSICAL ACTIVITY IN FIREFIGHTERS Medicine & Science in Sports & Exercised 1755

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APPLIED SCIENCES

FIGURE 1—Cardiorespiratory fitness and cardiovascular risk factors outcomes in function of physical activity and BMI.

1756 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

Copyright © 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
TABLE 5. Association between total weekly exercise (minIwkj1) and main outcomes.
Univariate Model Multivariate Model 1a Multivariate Model 2b
A P A P A P
CRF
MaxMETs 0.0054 G0.001 0.0034 G0.001 0.0024 G0.001
ETTT (s) 0.3425 G0.001 0.2102 G0.001 0.1556 G0.001
HRR (bpm) 0.0250 G0.001 0.0190 0.005 0.0143 0.05
RHR/HRR index j0.0031 0.01 j0.0024 0.06 j0.0023 0.1
Cardiovascular risk factors
SBP (mm Hg) 0.0057 0.4 0.0137 0.03 0.0134 0.05
DBP (mm Hg) j0.0059 0.1 j0.0010 0.8 j0.00004 1.0
TC (mgIdLj1) j0.0342 0.06 j0.0184 0.3 j0.0156 0.4
HDL (mgIdLj1) 0.0274 G0.0001 0.0173 0.002 0.0178 0.003
LDL (mgIdLj1) j0.0165 0.3 j0.0030 0.8 j0.0069 0.7
TG (mgIdLj1) j0.2615 G0.001 j0.1940 0.005 j0.1654 0.03
TC/HDL j0.0034 G0.001 j0.0020 0.004 j0.0020 0.01
Glucose (mgIdLj1) j0.0150 0.04 j0.0109 0.1 j0.0070 0.4
hs-CRP (mgIdLj1) j0.0079 0.008 j0.0068 0.03 j0.0078 0.03
a
Adjusted for BMI, age, and smoking status.
b
Adjusted for BMI, age, smoking status, and physical exercise intensity (sweat).

dimension. The RHR/HRR index was only significantly
associated (P = 0.02) with the duration dimension. Benefi-
cial effects were most evident when comparing those whose
reported exercise duration was Q30 min with those who
exercised G30 min (P = 0.003).
With respect to CVD risk factors, the frequency dimen-
sion showed significant associations with HDL (P = 0.001),
TG (P = 0.02), TC/HDL (P = 0.003), and fasting glucose
(P = 0.005), whereas hs-CRP levels decreased progressively
although the changes did not reach statistical significance
(P = 0.07). Neither the duration nor intensity dimensions
showed overall significant associations with measured CVD
risk factors. However, the mean values of HDL (P = 0.02)
and TG (P = 0.04) were significantly improved and TC/HDL
was borderline improved (P = 0.05, NS) in participants that
exercised at least 30 min per session compared with those
who exercised G30 min per session. In addition, participants
who reported sweating at least moderately had significantly
lower mean values of TG (P = 0.03) and borderline lower
TC/HDL (P = 0.06, NS) compared with those who reported
light sweating or who ‘‘do not exercise often.’’
The associations between the variable that combines the
effect of frequency and duration (total weekly exercise in
minutes per week) and the main outcomes are shown in
Table 5. Significant associations were found for all CRF
indicators even after multivariate adjustment except for the
HRR and RHR/HRR index in multivariate model 2.
Total weekly exercise was also positively associated
with HDL (P = 0.003) and negatively associated with TG
(P = 0.03), TC/HDL (P = 0.01) and hs-CRP (P = 0.03).
Surprisingly, although there was also a borderline associa-
tion with systolic blood pressure (SBP) (P = 0.05), the as-
sociation is positive. Hence, for every minute increase in
exercise per week, the SBP increased.
DISCUSSION
The present study on US firefighters strongly supports
previously described associations between PA or physical
exercise and CRF (27). The association with CRF was
strong across all three measured PA dimensions, as well as
with total weekly aerobic exercise (minIwkj1). Unfortu-
nately, the investigation also documents that 975% of the
career firefighters studied reported that they engage in
G150 min of aerobic exercise on a weekly basis, the mini-
mum recommended by the Centers for Disease Control and
Prevention and US Preventive Services Task Force guide-
lines (3). This fact, coupled with the high prevalence of
obesity, likely explains that 37% of our participants were
unable to exceed a CRF of 12 METs, the minimum exercise
capacity required for the safe performance of firefighting
according to the National Fire Protection Association.
The frequency of PA and total weekly exercise also
showed significant independent associations with multiple
CVD risk factors, which imply that increasing these behav-
iors among firefighters would improve their fitness and risk
profiles. We found that frequency of PA and total weekly
exercise was associated strongly with HDL, TC/HDL, and
TG but not LDL or TC. In a meta-analysis of cross-sectional
studies, Durstine et al. (7) found similar results for PA fre-
quency dimension as well as weekly exercise duration,
including significant dose–response relationships between
physical exercise and HDL increase, as well as TG decrease,
but not TC or LDL.
Although there is a general consensus that PA has a direct
role in the prevention of insulin resistance (12), it is not
known which PA characteristic is most helpful to prevent
APPLIED SCIENCES
diabetes. Because our study demonstrated a strong dose–
response correlation between the frequency dimension and
fasting glucose, we suggest that increasing the exercise fre-
quency may have the strongest effect.
Interestingly and despite the numerous reports that asso-
ciate exercise training with blood pressure reduction (8), our
study did not find beneficial associations for any of the three
dimensions evaluated. In fact, the present study found that
the SBP increased along with increasing minutes of aerobic
exercise per week, although the effect was not clinically
significant (and only borderline statistically significant).

PHYSICAL ACTIVITY IN FIREFIGHTERS Medicine & Science in Sports & Exercised 1757

Copyright © 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 The use of sweating, as in our study, as a measure of PA
intensity has been discussed in the literature (6,26). Because
decreased physical fitness levels may mean that less exercise
is needed for sweating, we expected this measure to have
limitations as a measure of exercise intensity. In addition,
the assessment of the activity intensity by sweating might be
distorted by individual body size. In fact, 27% of our obese
participants reported heavy sweating during physical exer-
cise. Despite all these disadvantages, we still found strong
associations between the intensity dimension and the
objective measurements of CRF, although the decrease of
TG and TC/HDL ratio was also significant and borderline
significant, respectively, in subjects who reported moderate
or heavy sweating.
The creation of a continuous variable estimating total
weekly aerobic exercise in minutes per week allowed us to
interpret the slope of various relationships in a linear
regression model. The similar CVD risk factor patterns in
association with total minutes of PA per week and with PA
frequency suggest that the benefits of increased weekly PA
duration are primarily mediated by the PA frequency.
Beyond the cross-sectional nature of the study, another
limitation of the present study is the self-report instrument
used to evaluate PA. Social desirability bias can lead to
overreporting of PA (29). However, this would have biased
our study toward negative results. Thus, our results may in
fact be conservative if they were indeed affected by social
desirability bias. Given that current exercise habits are easy
to remember and quantify and the study regarded present,
not past activity, recall bias should have been minimal.
Another limitation of the study is that we only measured
PA considered by participants to encompass exercise train-
ing and we did not consider other activities of daily living
that may enhance the energy expenditure. Nevertheless, not
considering those other activities most likely would have
biased our results toward the null hypothesis.
Our study has several important strengths. First, we had
multiple objective measures of CRF and CVD risk against
which to validate PA self-reports. Second, we had a large
sample size. Third, our sample had similar demographic and
anthropometric characteristics to those found in other epi-
demiologic studies of firefighters (5,16,31), suggesting that
the overall results of the present study can be generalized to
male career firefighters nationwide.
Although the beneficial effects of PA on CRF and CVD
APPLIED SCIENCES
risk profiles were evident in our study across all BMI cate-
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This investigation was supported by the Federal Emergency
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