Safety and Survival: Matters of the Heart for Women in the Fire Service

By Dominica D’Avella

Heart disease is widely believed to pose a greater threat to men, but it is also the number one killer of women in the U.S. A survey by the American Heart Association (AHA) found that only 13 percent of women thought that heart disease was their greatest personal health risk – even though more than half of those surveyed knew that heart disease is the leading cause of death in women. While female cardiac risk profiles look somewhat different than men’s across the lifespan, women need to take heart health seriously at all ages – earlier behaviors impact later risk. Women often have different heart attack symptoms than men, both in the month prior to and during a heart attack. Yet in the previously mentioned AHA study, many women reported their doctors never spoke to them about coronary risk.

Heart disease is not just the leading cause of death in the U.S., but also the leading killer of firefighters. Firefighters face far higher cardiac demands than non-firefighters, making heart health a key aspect of physical readiness in the fire service. Developing a clear picture of the full impact that firefighting activities have on women’s heart health is an ongoing effort, as most studies to date have focused on male firefighters. In-depth research on female firefighter health, like that now being conducted by Dr. Sara Jahnke for the Center for Fire, Rescue, and EMS Health Research, will help us better understand unique needs of female firefighters. Research conducted by the Houston Fire Department has found that female firefighters, in comparison to their male counterparts, have higher levels of PTSD, depression, stress, and suicidal ideation. These findings suggest that the influence of psychological well-being on both the cardiac and overall health of female firefighters is an area that needs to be explored.

We do already know that regardless of gender, a healthy heart is critical to responder safety, health, and survival in the fire and emergency services, and conscientious self-care is a key enabler of cardiac health. This article will discuss some of the straightforward – but often neglected – steps that female emergency responders can take to protect their hearts. One foundational aspect of improving outcomes is building stronger links between what the research tells us and how we put that into practice. Developing strategies to more effectively bridge the gap between what we know and what we do will ultimately save lives. In an era where we tend to look at body parts or systems in isolation, there is much to be gained by more holistically examining influences that impact cardiovascular and overall health.

The Greek philosopher Plato said, “The part can never be well unless the whole is well.” This is especially true in the realm of physical health. Nothing in the body occurs in isolation – all of our interdependent systems continually react to life’s demands to help us meet the challenges we encounter. In the fire and emergency services, the demands and the stakes are especially high – physical readiness and capability impact not just you as an individual, but also your crew, your department, and your community. Maximizing success is an imperative. That being the case, how do we promote and improve the health of both part (heart) and whole (body) for female firefighters?

Firefighter-specific assessments

As a starting point, all firefighters should thoroughly review the National Volunteer Fire Council’s (NVFC) position on firefighter physicals and the International Association of Fire Chief’s (IAFC) A Healthcare Provider’s Guide to Firefighter Physicals. These two resources provide an accessible path to medical assessment. Appropriate medical assessment of firefighters saves lives, but many departments struggle with the challenge of funding NFPA 1582 compliant annual physicals. The NVFC position provides an overview of different assessment options available to departments. The IAFC guide is something that any firefighter can bring to their personal physician so their annual physical is performed with the specific demands of firefighting in mind. Firefighters are unique patients, and the doctor needs to know it!

While it is imperative that your medical provider is well informed regarding the unique demands that female firefighters face, it is equally important that you are prepared to be your own advocate. Whether that means helping to get firefighter-specific resources into your physician’s hands, preparing questions prior to your exam, or making sure that your concerns are heard and addressed during a visit, it is crucial that you take an active rather than passive approach to your annual medical assessment. For instance, if high blood pressure runs in your family, review the new ACC/AHA blood pressure guidelines prior to your visit. Armed with the knowledge that lifestyle changes are the first course of action, you will also want to know when medication is warranted. The high cardiac demands and thermal stress of firefighting may influence which medications are more or less appropriate if it is deemed necessary.

As important as your annual physical is, it is just a first step. The results of a firefighter-specific medical assessment help identify your greatest needs and inform how to proceed. Based on that information, you can determine whether your attention needs to be focused on basic risk reduction to improve health, strategies to enhance fitness, or more towards the performance end of the continuum. Since health is the foundation upon which fitness and performance are built, we’ll start there. Upgrading self-care habits is key to heart health: quitting smoking, eating well, moving often, sleeping enough, and managing stress are major levers. To get the greatest benefit, we need to consider these behaviors all together because they influence one another. The NVFC’s Heart-Healthy Firefighter Program is a good resource for information and tools to help make positive changes as an individual or a department.

It is tempting to think that we can get away with less than optimal health behaviors, but the more we try, the more it becomes like racking up debt that we can’t repay. You can buy on credit for a while, but you’re likely just kicking the can down the road – sooner or later the money is due. In the case of physical health, being overextended means our bodies lose the ability to compensate for poor choices. The more poor choices we make and the more frequently we make them, the greater the danger of failure. Initially, those failures may manifest as aches, pains, and/or increased susceptibility to minor injuries or illnesses, but eventually the cumulative effect becomes more significant. This holds true in normal daily function, but the high physical demands of firefighting amplify the cardiac consequences of influences like using tobacco, eating junk food, sitting too much, sleeping too little, and chronic stress.

Core principles for healthy behaviors

There can be a lot of confusion about how to implement healthier behaviors. One reason is that methods are often substituted for principles. New methods – often with a profit motive – surface on a daily basis (think the latest diet, fitness tool, etc.). In contrast, principles are typically derived from an accumulation of scientific research and practice. Methods change often, principles endure. Chasing methods is like being a gerbil on a wheel – it seems like nothing is true for long and everyone disagrees about everything. Focusing on principles allows a clearer path to come into focus. Making health-supporting choices is easier when you don’t feel like the goal posts are always moving! One way to decrease resistance to heart-healthy choices in the firehouse is to simplify key messages.

Let’s look at this in the context of eating well. Writer Michael Pollan has summed up much of the existing nutrition research in just a few words: “Eat (real) food, not too much, mostly plants.” This simple guiding principle can go a long way towards cultivating nutrition habits that support heart health. To elaborate, concentrate on eating whole, unprocessed foods in reasonable portions, with a focus on plant foods like vegetables, whole grains, and beans. Just by starting to increase your intake of the good stuff (nutrient dense foods), you will naturally reduce some of the things that tend to be less good for the heart (energy dense, processed foods; excessive portions; sugary beverages). For more detailed information, look up Harvard School of Public Health’s ‘Healthy Eating Plate.’ Firefighters also need to keep hydration a priority – dehydration increases cardiac strain – so sip water throughout the day.

Physical activity doesn’t have to be complicated either. Physical therapist Gray Cook is well known for saying, “First move well, then move often.” This succinct statement conveys a lot of important information. First and foremost, we need to consider movement before exercise. The human body was designed to move – deviating from that biological imperative creates a cascade of problems. We need to establish movement habits throughout our day that interrupt sitting and regularly allow our joints to access their full ranges of motion. Doing so helps keep us healthy and functional. Engaging in repetitive and/or restricted patterns of movement can diminish our ability to perform outside of those ranges and impair the health and resilience of our tissues. We need quality, variety, and consistency in our physical activity for health, and then we can increase volume and intensity to build greater fitness.

It should not come as a surprise that ‘enough’ physical activity for firefighters is more than what may be enough for the general population. The 2008 Physical Activity Guidelines for Americans recommend that adults get a minimum of 150 minutes a week of moderate intensity physical activity, avoid inactivity, and engage in muscle-strengthening activities that involve all major muscle groups at least two days per week.  Think of this as the baseline upon which firefighter-specific fitness gets built. First achieve this, and then develop greater work capacity through appropriate progressive overload to give your body time to adapt to the stress imposed and become more resilient. For women in the fire service, focusing on physical training that develops job-related movement capacity and emphasizes good technique can help you do the job safely and lessen injury risks.

Because firefighting is physically demanding, there is often an assumption that all physical training must be high-intensity and performance oriented. In reality, progress along the continuum must be earned for long-term sustainability. Putting the body through the rigors of maximal effort without ensuring that more basic health and fitness concerns have been addressed is, at best, a recipe for injury and illness and, at worst, can be life-threatening. In an average year, there are close to 70,000 injuries and 100 fatalities in the fire service. Strain, sprain, or muscular pain represents the largest injury category, and cardiac events are the leading cause of firefighter fatalities. Taking incremental steps to increase general physical preparedness and work capacity is a logical starting point to address and minimize these risks.

The connection between musculoskeletal injury and heart health may not be obvious, but anything that sidelines you from regular training can increase cardiac strain by returning you to duty in a deconditioned state. For example, female athletes have been shown to experience higher rates of anterior cruciate ligament (ACL) injuries. When rehabbing a knee injury, it is common for your normal level of aerobic activity to be diminished. Consequently, part of the return to duty process needs to be ensuring that not only is the injured joint ready to resume the demands of the job, but also that any associated losses in aerobic fitness due to reduced overall activity are addressed. Fitness is multifaceted.

Health-related components of fitness

The health-related components of fitness (HRCF) include cardiorespiratory fitness, muscular strength and endurance, flexibility, and body composition. Cardiovascular conditioning can help us do more work; it can also allow us to do the same amount of work with less effort (become more efficient). NFPA 1582 specifies that firefighters should be able to perform at least 12 metabolic equivalents (METs) as the minimum level of aerobic capacity. The goal of performance training should be to exceed this target.

A 2012 study by Jahnke et al. found that only 22.2 percent of career female firefighters and 7.7 percent of volunteer female firefighters in the population analyzed met this standard based on aerobic capacity estimates. A new study by Kirin et al. suggests that the percentage of female firefighters meeting the benchmark is higher, but that the percentage falling short increases by age cohort. Future research will more clearly answer this question, but female firefighters have a clear target for establishing aerobic capacity commensurate with the demands of the job. Heart attacks and sudden cardiac deaths are most likely to occur during the high demands of fire suppression activities; aerobic capacity is something that can and should be directly measured in firefighter physicals to anticipate how the heart will respond to high-level demands. Females have smaller lungs and higher essential body fat than males, so maximal aerobic capacity tends to be slightly lower. With training, the 12 MET standard is very achievable.

As important as cardiovascular training is to heart health, it is not the only physical training that matters. Firefighters need a balance across all of the HRCF to do the job safely and effectively, and females sometimes neglect strength training. Developing competency and capacity in fundamental movements (push, pull, squat, lunge, rotate) is a priority. Deficits in muscular strength or muscular endurance, compromised ranges of motion, and/or excess body weight can all contribute to inefficiency that ultimately forces the heart to work harder to meet the demands imposed by firefighting activities.

Body composition also has important implications. Extra weight not only creates greater demand on the heart, but also on the musculoskeletal system, increasing wear and tear on joints. Joints that function less optimally can make physical activity harder, thereby increasing the work that the heart needs to do. It is desirable to have more lean body mass (muscle) and less fat mass not only for the obvious benefits of having more muscle, but because fat is active endocrine tissue – it biochemically shifts many processes that occur in the body. Women have higher essential body fat than men, but still need to maintain body composition in the healthy range for females.

Obesity increases the risk of high blood pressure, high cholesterol, and diabetes, all of which also increase cardiac risk. Excess fat mass also impedes our ability to dissipate heat, and thermal stress is one of the ways that firefighting increases cardiac strain. Interestingly, it appears that both body mass index (BMI) and waist circumference measurements may underestimate obesity in female firefighters in comparison to objective measurement of body fat percentage by bioelectrical impedance (Jahnke et al., 2012). Further research is needed, but this suggests that female firefighters should be cautious of using only BMI or waist circumference as an acceptable proxy for actual body composition.

Additional considerations

Other factors, such as inadequate sleep and excess psychological stress impose additional demands on the heart. Improving sleep quality and stress management strategies are integral parts of a comprehensive self-care program. Depression can increase cardiac risk, and female firefighters seem to have higher rates of being at risk for depression than women in the general population (Jahnke et al., 2012). Occupational stress may contribute to depression risk as well as the smoking rates seen in female firefighters. Gender differences in physiological response to psychological stress or trauma are just starting to be understood. Women should be aware of these factors and how they may impact heart health so they can adapt their health and fitness efforts to best meet their personal well-being needs.

Smaller body size compared to male firefighters means that, for most women, firefighting gear and tools represent a greater percentage of body weight, thereby increasing physical demands. Perhaps less obvious is the risk posed to female firefighters from ill-fitting protective gear. More than 58 percent of women surveyed by iWomen reported this to be an issue (Jahnke et al., 2012). Since smoke exposure has been identified as both an acute and chronic potential occupational cardiovascular hazard, properly fitting personal protective equipment should be a priority for every female firefighter.

Future research will illuminate these and many other firefighter heart health issues in greater detail, but much can be gained by focusing on critical behaviors that we already know help improve safety and survival. Daily behaviors have a significant influence on women’s heart health, and there are many ways to reduce the risk of having a cardiac event. Focus on what you can control, advocate for a fire service culture of health, and stay safe. Culture changes one firefighter at a time, and we need to keep drilling the fundamentals until they become the norm for women in the 21st century fire service.

Dominica D’Avella is the health and wellness coordinator for the Massachusetts Call/Volunteer Firefighters Association and New England Volunteer Fire and EMS Coalition. She is an ACE certified health coach and peer fitness trainer, ACSM certified exercise physiologist, and NSCA certified strength and conditioning specialist. Her work across the domains of public health, community health, and individual health brought her to the fire service. Dominica is passionate about empowering individuals to maximize their health, fitness, and performance through informed self-care. Contact and social media information can be found on her web site at