Alcohol Use, Exercise, and Physical Fitness among Career Firefighters

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Title:
Alcohol Use, Exercise, and Physical Fitness among Career Firefighters
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1 online resource (64 p.)
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english
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Gardner, Anna Katlyn
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University of Florida
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Doctorate ( Ph.D.)
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University of Florida
Degree Disciplines:
Health and Human Performance, Health Education and Behavior
Committee Chair:
BARRY,ADAM E
Committee Co-Chair:
CHANEY,ELIZABETH H
Committee Members:
WEILER,ROBERT M
DODD,VIRGINIA JONES

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Subjects / Keywords:
alcohol -- bmi -- exercise -- firefighter
Health Education and Behavior -- Dissertations, Academic -- UF
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Health and Human Performance thesis, Ph.D.
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theses   ( marcgt )
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Abstract:
This paper outlines three studies for the dissertation of Anna Gardner. The research seeks to investigate rates of alcohol use, physical activity, and levels of physical fitness among career firefighters. Additionally, the alcohol activity association is assessed. Data were collected from a convenience sample of firefighters from Alachua Country Fire Rescue (ACFR), using a web delivered, self administered health assessment designed to assess exercise and drinking behaviors. A comprehensive fitness assessment included measures for cardiovascular fitness, muscular endurance, muscular strength, and flexibility to determine overall fitness levels among the firefighters. Descriptive (i.e. mean, standard deviation, frequencies, percentages) and inferential (i.e. multiple linear regression, hierarchical binary logistic regression, and MANOVA) statistics were used to assess the research questions outlined herein. Results will add to the current literature on firefighter alcohol consumption. Additionally, results will assist intervention and policy efforts towards reducing alcohol use and abuse among firefighters.
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In the series University of Florida Digital Collections.
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Includes vita.
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Includes bibliographical references.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Anna Katlyn Gardner.
Thesis:
Thesis (Ph.D.)--University of Florida, 2014.
Local:
Adviser: BARRY,ADAM E.
Local:
Co-adviser: CHANEY,ELIZABETH H.

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UFE0046497:00001


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ALCOHOL USE, EXERCISE, AND PHYSICAL FITNESS AMONG CAREER FIREFIGHTERS By ANNA GARDNER A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2014

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2014 Anna Gardner

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3 ACKNOWLEDGMENTS I would like to thank my committee chair, Dr. Adam Barry, for your constant guidance throughout the past four years. I am grateful for the numerous opportunities you provided to advance my education and increase my enthusiasm for research. Your trust and f aith in my abilities, along with continual support to strive for excellence, have made me the scholar I am today I am also thankful that you cared for me as an individual, mentoring and encouraging me to maintain balance in life through my affairs outside of school. I would also like to extend my sincere appreciation to the remaining members of my dissertation committee: Drs. Bob Weiler, Beth Chaney, and Virginia Dodd. Thank you for the time and effort you have put forth throughout my doctoral career, but especially in regards to this dissertation. Your knowledge and expertise has significantly improved the value and wholesomeness of this work. Your continuous encouragement and support throughout my doctoral experience at U F is greatly appreciated. Thank y ou to Dr. Tony Delisle, for without your collaboration, this dissertation would not have been possible. You opened doors so I could explore my own interests, and supported me the entire way. Our working relationship and friendship are invaluable asset s to be sustained for years to come. I must also thank the firefighters of Alachua Country Fire Rescue for you r belief in my research and willingness to participate. Specific thanks to Chief Jim Bendel for your desire and support in creating collaboration betwe en ACFR and UF. In addition, I am grateful for the time and effort of Amy Childs, Alachua County Wellness Coordinator, for your integral role in supporting this research project and assisting with data collection.

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4 I would like to thank my parents for insti lling in me a drive and determination to achieve great things. There is no greater motivation then your unconditional love which has continuously overlooked my flaws and celebrated my strengths. And finally, thank you to my husband, Dan Thank you for your unselfishness, and willingness to put your dreams on hold in order that I could pursue mine. You have stood by me through it all, encouraging me when I felt unconfident, rejoicing with me in victories both big and small, and loving me no matter what.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ ............... 3 LIST OF TABLES ................................ ................................ ................................ ........................... 7 LIST OF ABBREVIATIONS ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ................................ ..... 9 C H A P T E R 1 INTRODUCTION ................................ ................................ ................................ .................. 10 2 COVARIATES OF ALCOHOL CONSUMPTION AMONG FIREFIGHTERS .................. 15 Background ................................ ................................ ................................ ............................. 15 Material & Methods ................................ ................................ ................................ ................ 16 Survey Items ................................ ................................ ................................ .................... 16 Study Variables ................................ ................................ ................................ ............... 18 Drinking frequency ................................ ................................ ................................ .. 18 Binge drinking status ................................ ................................ ................................ 18 AUDIT C sc ore ................................ ................................ ................................ ........ 18 Demographic covariates ................................ ................................ ........................... 18 Statistical Analysis ................................ ................................ ................................ .......... 19 Results ................................ ................................ ................................ ................................ ..... 19 Discussion ................................ ................................ ................................ ............................... 20 3 ASSESSING THE ALCOHOL ACTIVITY ASSOCIATION AMONG A SAMPLE OF CAREER FIREFIGHTERS ................................ ................................ ................................ .... 26 Background ................................ ................................ ................................ ............................. 26 Material & Methods ................................ ................................ ................................ ................ 27 Survey Items ................................ ................................ ................................ .................... 27 Alcohol consumption ................................ ................................ ............................... 27 Physical activity/exercise ................................ ................................ ......................... 28 Study Variables ................................ ................................ ................................ ............... 28 Drinking status ................................ ................................ ................................ ......... 28 AUDIT C score ................................ ................................ ................................ ........ 28 Exercise status ................................ ................................ ................................ .......... 29 Typical weekly exercise ................................ ................................ ........................... 29 Control variables ................................ ................................ ................................ ...... 29 Statistical An alysis ................................ ................................ ................................ .......... 29 Results ................................ ................................ ................................ ................................ ..... 30 Discussion ................................ ................................ ................................ ............................... 30

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6 4 BODY MASS INDEX VERSUS PERCENT BODY FAT AS AN INDICATOR OF OVERWEIGHT/OBESITY AND PHYSIC AL FITNESS AMONG CAREER FIREFIGHTERS ................................ ................................ ................................ ..................... 34 Background ................................ ................................ ................................ ............................. 34 Material & Methods ................................ ................................ ................................ ................ 36 Study Measures ................................ ................................ ................................ ............... 37 Cardiovascular fitness ................................ ................................ .............................. 37 Muscular strength ................................ ................................ ................................ ..... 37 Muscular endurance ................................ ................................ ................................ 38 Lower back and hamstring flexibility ................................ ................................ ...... 39 Body composition ................................ ................................ ................................ .... 39 Statistical Analysis ................................ ................................ ................................ .......... 40 Results ................................ ................................ ................................ ................................ ..... 41 Discussion ................................ ................................ ................................ ............................... 43 5 CONCLUSIONS ................................ ................................ ................................ .................... 49 LIST OF REFERENCES ................................ ................................ ................................ ............... 54 BIOGRAPHICAL SKETCH ................................ ................................ ................................ ......... 64

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7 LIST OF TABLES Table page 2 1 Participant characteristics ................................ ................................ ................................ .. 25 3 1 Participant characteristics ................................ ................................ ................................ .. 33 3 2 Linear regression predicting AUDIT C score ................................ ................................ .... 33 4 1 ACSM recommendations for percent body fat ................................ ................................ .. 47 4 2 Participant characteristics ................................ ................................ ................................ .. 47 4 3 Body composition classification by body fat versus BMI ................................ ................. 48 4 4 Average fitness test scores ................................ ................................ ................................ 48

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8 LIST OF ABBREVIATIONS ACE American Council on Exercise ACFR Alachua County Fire Rescue ACSM American College of Sports Medicine AUC Area under curve AUDIT C Alcohol Use Disorders Identification Test BMI Body mass index BRFSS Behavioral Risk Factor Surveillance System LTEQ Leisure Time Exercise Questionnaire MANOVA Multiple analysis of variance ROC Receiver operating characteristics WFI Wellness Fitness Initiative

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9 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy ALCOHOL USE, EXERCISE, AND PHYSICAL FITNESS AMONG CAREER FIREFIGHTERS By Anna Gardner May 2014 Chair: Adam Barry Major: Health and Human Performance This paper outlines three studies for the dissertation of Anna Gardner. The research seeks to investigate rates of alcohol use, physical activity, and levels of physical fitness among career firefighters. Additionally, the alcohol activity association is a ssessed. Data were collected from a convenience sample of firefighters from Alachua Country Fire Rescue (ACFR) using a web delivered, self administered health assessment designed to assess exercise and drinking behaviors. A comprehensive fitness assessm ent include d measures for cardiovascular fitness, muscular endurance, muscular strength, and flexibility to determine overall fitness levels among the firefighters. Descriptive (i.e. mean, standard deviation, frequencies, percentages) and inferential (i.e. multiple linear regression, hierarchical binary logistic regression, and MANOVA) statistics were used to assess the research questions outlined herein. Results will add to the current literature on firefighter alcohol consumption. Additionally, results will assist intervention and policy efforts towards reducing alcohol use and abuse among firefighters.

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10 CHAPTER 1 INT RODUCTION The United States fire service consists of an estimated 1,082,500 firefighters, including 278,300 career and 804,200 volunteers (United States Fire Administration, 2013). The firefighting occupation is characterized by long hours (typically 24 ho ur shift work), disrupted sleep, high intensity labor, and exposure to potential dangers such as blazing fires and thick smoke, hazardous materials (i.e. gas leaks, chemical spills), and structurally unsafe buildings (Murphy et al., 1999). Considering su ch an intense working environment firefighters must maintain optimal health status, including physical, emotional, and mental well being. To better understand the health status of firefighters, more research related to their health behaviors is needed. W hile research has investigated several health behaviors and outcomes among firefighters (i.e. obesity, cardiovascular health, and smoking) relatively little is known about quantity and f requency of alcohol consumption among this population. Identifying th e alcohol use among firefighters is critical to ensuring optimal levels of job performance and safety. For instance, drinking while on duty, or intoxication off duty that lingers into shift work, may impair entially lead to injury, permanent disability, or even death for themselves or fellow firefighters. While research has assessed alcohol consumption related to stress and trauma (i.e. post traumatic stress disorder) among firefighters (Murphy, et al., 1999; Bacharach et al., 2008; McFarlane, 1998; Boxer & Wild, 1993), few studies have investigated levels of alcohol consumption among firefighters in general (Haddock et al., 2011; Carey et al., 2011). Among their convenience samples, high levels of alcohol consumption were observed. Among 459 career firefighters, Haddock et al. (2011) documented drinking frequency, on average, of ten days per month, with three or more drinks per occasion.

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11 Also, 56% binge drank (5 or more drink s on one occasion) in the past month. Carey et al. (2011) observed s imilar drinking levels among 112 career firefighters, where 80% used alcohol (mean of 1.6 1.7 drinks per day), 56% binge drank (4+ drinks for men, 3+ drinks for women) and 14% binge dra nk two or more times per week. These levels exceed that of the general population, where approximately 55% of adults have had at least one drink in the past 30 days, and 17% binge drank (Centers for Disease Control and Prevention, 2012). Furthermore, alco hol consumption among firefighters surpasses that of college students, a subgroup of the adult population who exhibit the highest drinking rates of any demographic [62% consumed alcohol in the past 30 days and 21% binge drank 1 2 times in the last two week s] (American College Health Association, 2012). Thus, b ased on the currently available literature, it appears firefighters represent an at risk drinking group. One purpose of this dissertation research is to assess the quantity and frequency of alcohol con sumption among firefighters, along with the covariates that influence consumption levels. Findings from this study will add to the current literature on firefighter alcohol consumption, as well as inform intervention and policy efforts aimed at reducing al cohol use and abuse among firefighters. In addition to alcohol consumption, exercise represents a salient health behavior of firefighters c onsidering the physically demanding nature of the job Simply put, firefighters must maintain optimal levels of ca rdiorespiratory fitness, often achieved by increasing levels of exercise in order to perform their job well (International Association of Fire Chiefs, 2008). The Wellness Fitness Initiative a task force dedicated to improving overall health among firefi ghters, recommends 60 90 minutes of on duty exercise (International Association of Fire Chiefs, 2008) O ff duty exercise is also promoted due to variability in scheduling, calls, and training that

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12 oftentimes limits the on mplete a full workout (Soteriades et al., 2011). Interestingly, the aforementioned health behaviors among firefighters (i.e. exercise and alcohol consumption) parallel scientific literature outlining an incongruous, positive association between alcohol c onsumption and physical activity/exercise. Specifically, those who drink alcohol are more likely to be physically active than non drinkers (Pate et al., 1996; Dunn & Wang, 2003, Piazza & Barry, 2012; French et al., 2009, Westerterp et al., 2004). In fact, across all age groups, studies document a dose response relationship between alcohol consumption and physical activity level. In other words, as drinking increases, so does physical activity (Piazza & Barry, 2012). A nother purpose of this dissertation r esearch is to examine the association between drinking and exercise among firefighters, a group among which this relationship has not been previously studied. In line with physical activity, physical fitness, which refers to the ability to perform activit on Physical Fitness and Sports, 1971), is also an essential facet of health and job performance for firefighters. Comprised of multiple components (e.g. cardiovascu lar fitness, muscular strength high intensity demands it faces during rescue calls. B ased on the need for high levels of fitness (often achieved through high le vels of exercise), one might assume firefighters would maintain a rather lean, muscular build with low levels of adiposity. Typically, adiposity among the general adult population is assessed with the standard measure of body mass index (BMI), as it allows for quick, non invasive, and inexpensive measurement. However, a limitation of BMI is its likelihood to overestimate obesity in populations with muscular builds (e.g. athletes). F ew

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13 studies (Jitnarin et al., 2013; Poston et al., 2011a) have assessed the a ccuracy of BMI in determining overweightness/obesity among firefighters compared to more accepted measures (e.g. body fat percentage). These studies are limited by a) use of male only samples (Jitnarin et al., 2013; Poston et al., 2011a), b) assessing only overweightness (Jitnarin et al., 2013) or obesity et al., 2013). Furthermore, only one study has assessed the impact of body composition on physical fitness among firefighters (Poston et al., 2011a) This study was limited by the lack of a comprehensive measure of fitness, as muscular endurance tests were not included. Therefore, two additional purposes of this dissertation research include a) identifying con current validity of BMI and percent body fat as an indicator of body composition among firefighters, and b) investigating differences in physical fitness levels based on adiposity status (i.e. non overweight/obese, overweight (but not obese), and obese) as estimated by BMI or measured by body fat percentage. Overall, the proposed research will supplement existing knowledge related to salient health behaviors (i.e. alcohol use and physical activity) and outcomes (i.e. BMI, body fat, and physical fitness) of firefighters. Findings can inform future public health and occupational interventions aimed at decreasing alcohol use and abuse, while increasing physical activity on and off duty. Information related to rates of alcohol consumption and physical activity, along with further research investigating the impact of these behaviors on health and job performance, may also serve as a catalyst changes in fire service policy and procedures. This work will also provide rationale for acceptable measures of obesity with in the firefighting occupation, followed

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14 firefighters. L ikewise, knowledge related to the effects of obesity on fitness, paired with future for mandates.

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15 CHAPTER 2 COVARIATES OF ALCOHOL CONSUMPTION AMONG FIREFIGHTERS Background Research has examined several health behaviors and outcomes among firefighters (i.e. obesity [Poston et al., 2011a; Choi et al., 2011] cardiovascular health [Soteriades et al., 2011; Kales et al., 2007] smoking [Carey et al., 2011; Haddock et al., 2011] ), but little is known about rates of alcohol consumption within this occupation. While studies have alcohol consumption related to stress and trauma (i.e. post traumatic stress disorder) (Murphy et al., 1999; Bacharach et al., 2008; McFarlane, 1998; Boxer & Wild, 1993), only two investigations have indentified general levels of alcohol consumption (Haddock et al., 2012 : n = 459 ; Carey et al., 2011 : n = 112 ). Overall, consumption levels, based on frequency and quantity, wer e high. In both studies, 80% or more of the sample were current drinkers, with the majority (56%) having binge drank in the past 30 days (Haddock et al., 2012 ; Carey et al., 2011) Additionally Carey et al. (2011) identif ied 14% binge drank two or more ti mes per week in the past month In terms of frequency, firefighters drank, on average, ten days per month (Haddock et al. (201 2 ) with the average q uantity of consumption ranging from approximately 1.5 (Carey et al., 2011) to three (Haddock et al., 2012) d rinks per occasion. These levels surpass alcohol consumption among the general adult population (55% have had at least one drink in the past 30 days, and 17% binge drank; Centers for Disease Control and Prevention, 2012) and college students a subgroup of the adult population who exhibit the highest drinking rates of any demographic (62% consumed alcohol in the past 30 days and 21% binge drank 1 2 times in the last two weeks; American College Health Association, 2012). While it appears firefighters represent an at risk drinking group the dearth of literature currently available is limited by geographic region (e.g. one sample from the Northeast and one

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16 from the central United States) and also fails to further investigate factors impacting firefighte r alcohol consumption The purpose of this study is to assess the quantity and frequency of alcohol consumption among career firefighters from a department located in the Southeast United States (an area not previously sampled), along with the covariates t hat influence consumption levels. Material & Methods This study was approved by the University of Florida Institutional Review Board. A convenience sample of career firefighters was recruited from a local fire department. This sample was selected due to an ongoing collaboration between the university and fire department. This fire department, located in North Central Florida, serves a county of approximately 250,000 people within 969 square miles (United States Census Burea u, 2012), and provides both medical and fire rescue services. Data was collected over a 6 week period during the summer of 2013. A self administered health assessment survey was accessed through a secure, online employee portal The survey contained 33 to tal items related to smoking and tobacco use, physical activity, alcohol consumption, sleep habits, nutrition, and demographics. Those wishing to participate in the study indicated their consent prior to beginning the survey. The time to complete the surve y w as approximately 10 15 minutes and all responses were anonymous. Survey Items Self report measures for alcohol consumption included 7 total items Three i tems measuring hazardous drinking were taken directly from the Alcohol Use Disorders Identificatio n Test (AUDIT C) (Bush et al., 1998). These items included: a) How often do you have a drink containing alcohol? [never, monthly or less, 2 4 times a month, 2 3 times a week, 4 or more times a week], b) How many drinks do you have on a typical day when you are drinking? [1 2 drinks, 3 4 drinks, 5 6 drinks, 7 9 drinks, 10+ drinks], and c) How often do you have 6 or more

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17 drinks on one occasion? [never, less than monthly, monthly, weekly, daily or almost daily]. Respondents were informed that one drink is equi valent to a 12 ounce beer, a 5 ounce glass of wine, or a drink with one shot of liquor. The AUDIT C has not been previously administered among firefighters. However, data from the AUDIT C has been shown to be valid and reliable among a variety of populatio ns (Bradley et al., 2007; Frank et al., 2008; Rumpf et al., 2003; Dawson et al., 2005). Three items related to quantity of consumption and intoxication were taken from the Behavioral Risk Factor Surveillance System (Centers for Disease Control and Prevent ion, 2011). what is the largest number of ts indicated a number from 0 through 7. The BRFSS has been used in studies among firefighters, but not assessing alcohol consumption (Haddock, et al., 2012). Still, data from the BRFSS has been shown to be valid and reliable among other populations (Link & Mokdad, 2005; Stein et al., 1993; Midthjell et al., 1992). College Health Assessment ( American College Health Association 2008) to assess perception of quantity of alcoh ol consumption among peer firefighters. Respondents indicated a number from

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18 Study Variables Drinking frequency The variable drinkin 4 times a month, 2 3 times a week, 4+ times a week). Binge drinking status Binge drinking status was measured accor t offs by Wechsler et al. (1995b ), binge drinkers were categorized as males who consumed five or more drinks, or females w ho consumed four or more drinks, on any occasion over the past 30 days. AUDIT C score AUDIT C score was calculated according to standard scoring procedures (Bush et al., 1998). Values range from 0 to 12, with a score of 7 or more for men, and 5 or more fo r women, indicating hazarding drinking behavior (DeMartini & Carey, 2012). Demographic covariates Covariates included smoking status, smokeless tobacco use, exercise status, number of hours of sleep (on and off duty), diagnosis of sleep disorder, race, s ex, time in fire service, and active or light duty status. These covariates were selected based on prior research identifying an association with alcohol consumption (Ma et al., 2000; Reed et al., 2007 b ; Piazza & Barry, 2012; Carey et al., 2011; Stein & Fr iedmann, 2005; Wilsnack et al., 2000; Nolen Hoeksema, 2004; Substance Abuse and Mental Health Services Administration, 2012). Based on the recommended 7 8 hours of sleep for adults (Morgenthaler, 2013; National Sleep Foundation, 2013), the reported number of hours of sleep on duty and off

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19 White races, the variable race a covariate due to the low number of respondents (n = 69) indicating their age. Statistical Analysis Statistical analyses were carried out using Predictive Analytics SoftWare Version 21. Descriptive statistics were used to assess the number of current drinkers and rates of hazardous drinking. Exploratory data analysis was used to ensure all assumptions were met. Hierarchical binary logistic regression assessed the ability of several covariates (outlined below) to predict the dependent variable binge dr inking status Additionally, hierarchical multiple linear regression was used to assess the ability of several covariates (outlined below) to predict the dependent variable, AUDIT C score. For both regression analyses, Block 1 included the personal covar iates race and sex. Block 2 included the behavioral covariates smoking status, smokeless tobacco use, exercise status, number of hours of sleep (on and off duty), and diagnosis of sleep disorder. Block 3 included the vocational covariates time in service and work status (i.e. active or light duty). Results The final sample size included 160 career firefighters. The majority were White (79.8%) male s (84.8%), who on average, had worked as a firefighter for 14.3 ( 8.8) years. The mean age was 37.5 ( 9.2) y ears I t is worth noting only 69 participants indicated their age. The mean See Table 2 1 for descriptive statistics and health related behaviors. T he majority of this sample of firefighters consumed alcohol (89.3%), with approximately one third (33.7%) having binge drank in the past 30 days. The average number of

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20 drinks per occasion over the past 30 days wa s 3.76 ( 3.37), and the largest number of drinks on any occasion in the past 30 days having a mean of 4.9 ( 3.81) drinks. Average AUDIT C score for the sample was 4.11 ( 2.45) which is below the cut off indicating hazardous drinking behavior. For the b inary logistic regression, only the full model containing all covariates was 2 (10, N = 129) = 18.668, p = .045. The model explained between 13.5% (Cox and Snell R square) and 18% (Nagelkerke R squared) of the variance in binge drinking status, and correctly classified 71.3% of cases. Race ( p = .03) and time of service ( p = .001) were the only covariates that made a statistically significant contribution to the model. An odds ratio of 4.48 indicated that, after controlling for ot her factors in the model, White respondents were approximately 4.5 times more likely to binge drink compared to non White respondents (95% CI [1.15, 17.4]). In addition, an odds ratio of 0.92 indicated that, after controlling for other factors in the model for each additional year of service, firefighters were 1.08 times less likely to binge dra nk (95% CI [ 0.87 0.97 ]). Due to low correlations with the dependent variable (AUDIT C score), work status (r = .018), smoking status (r = .008), and exercise status (r = .003) were omitted from the linear regression model. A high correlation existed between time as a firefighter and age (r = .833). Considering this, along with the low number of respondents that indicated age, age was also omitted from the model. The model did not achieve statistical significance; however, time of service was a statistically significant predictor o f AUDIT .244, p = .012). Discussion This study investigated alcohol use and covariates of consumption among a sample of career firefighters. Average quantity of consumption among this sample (3.76 3.37 drinks ) was similar to that observed b y Haddock et al. (2012; 3+ drinks per occasion), but rates of binge

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21 drinking were lower compared to previous studies among this occupation. For example, approximately one third of this sample binge drank in the past 30 days, while Haddock et al. (2012) an d Carey et al. (2011) identified 56% of the samples binge drank. D rinking levels observed in this study exceed those of the general adult population, including college students. In assessing the covariates of binge drinking among this sample, White respon dents were more likely to binge drink compared to other races/ethnicities. This finding echoes previous literature among the general population (Substance Abuse and Mental Health Service s Administration, 2012; Falk et al., 2006) and adolescents (Vega et al., 1993; Blum et al., 2000) where Caucasians had higher rates of alcohol consumption compared to all other races/ethnicities. Time of service was also a statistically significant cova riate of binge drinking, in that the longer the time of service, the less likely a firefighter was to binge drink. Previous research has not assessed the association between length of service as a firefighter and alcohol use Two plausible explanations for this relationship stem from a) the association between drinking and Studies among the general adult population (Wilsnack et al., 2000; Nolen Hoeksema 2004; Substance Abuse and Mental Health Services Administration, 2012 ) and one study among career firefighters (Carey et al., 2011) have identified alcohol consumption decreases with age. Wilsnack et al. (2000) reported that as individuals age, they are more likely to abstain fro m drinking altogether. Considering age was highly correlate d with time of service as a firefighter, the association between time of service and binge drinking identified in this study may likely be mediated by age.

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22 While research has not previously assess ed the association between length of service as a firefighter and alcohol use, literature regarding Social Identity Theory ( Tajfel & Turner, 1979 ) and college students alcohol consumption may provide a plausible explanation. Briefly, Social Identity Theo ry posits that regardless of your personal attitude towards a behavior, you are more likely to partake in the behavior if the key referent group with which you identify yourself supports the behavior, or you perceive this referent group to support the beha vior ( Tajfel & Turner, 1979 ). Among 620 undergraduates, Reed et al. (2007a) identified a positive association between alcohol consumption and perception of peer acceptability of heavy drinking. Similarly, Johnston and White (2003; n = 289) and Neighbors e t al. (2010; n = 3,752) found that the stronger a student identified with a specific referent group, the stronger the association between perceived norms for drinking among the referent group and their own drinking. Research has determined that firefighte rs value identity (Thu rnell Read & Parker, 2008; Olofs son, 2013) and place high importance on group cohes ion (Thurnell Read & Parker, 2008). Specifically, firefighters focus on reliability, trustworthiness, and willingness to commit to the occupation (Olo fs son, 2013). A unique social climate exists among firefighters, who often eat, sleep, and socialize with one another for 24 hour periods at a time (Beaton et al., 1997). Therefore, firefighters are likely to identify their peers as a key referent group. Considering th eir close interaction, along with occupational responsibilities that depend highly on teamwork, the cultural, even somewhat familial, connection among f irefighters is not surprising. S ocial integrati on is oftentimes a priority for all firefi ghters but especially newer recruits (Myers, 2005 ). Thus, it is likely that newer recruits to the service may enact health behaviors (such as alcohol consumption and binge drinking) perceived to be acceptable in order to assimilate with their colleagues quicker. Firefighters from this sample estimated their peers drank, on average, 6

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23 drinks the last time they consumed alcohol. In actuality, the mean number of drinks (according to one and four. Thus, it appears the firefighters overestimate d and may factor into the increased likelihood of binge drinking among those with lesser time in the service. F uture research should invest igate the existence (actual or perceived) of acceptance, identity and norm s of alcohol consumption within the firefighter culture as well as if and how these factors influence differences in alcohol consumption by time spent in the service. O verall, the observed levels of alcohol consumption among this sample of firefighters are cause for concern, considering the potential for overlap with, and influence on, shift work. While research is needed to assess the effects of alcohol consumption on j ob performance among firefighters, studies have shown decreases in cognitive functions and psychomotor performance among other professions. For instance, pilots exhibited post intoxication deficits in flight performance and correctly carried out fewer dir ectives from air traffic controllers eleven hours after reaching a blood alcohol level of 0.10 or greater, (Petros et al., 2003). Among surgeons, previous day intoxication inhibited cognitive, perceptual, and psychomotor aspects of surgical performance th e following morning, even after blood alcohol levels had returned to zero (Kocher et al., 2006). Furthermore, such detriments to performance among surgeons have been reported to persist as late as 4 pm the day after drinking (Gallagher et al., 2011). Stu dies assessing alcohol consumption among active military personnel have prompted concern regarding force readiness et al., 2012; Kline et al., 2010). The concept of for ce readiness also applies to firefighters, as the

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24 alcohol use on duty, or lingering effects from consumption that occurred while off duty, would inhibit force readiness among firefighters. Thus, investigations into off duty drinking rates among firefighters are warranted to identify and address alcohol use and abuse and to thwart any potential impact of on duty performance. It is important to note this study is not without limitations. The use of self report data presents an inherent limitation, as participants may not have responded honestly or accurately. To inhibit the influence of this limitation on study findings, all responses were kept anonymous, and o nly instruments previously shown to result in valid and reliable data were used. The proportions for sex and race/ethnicity were representative of the overall population of firefighters (Bu reau of Labor Statistics, 2011). However, the use of a convenience sample which resulted in relatively low frequencies for female and non White participants decrease s the ability to generalize study findings. Thus, future investigations should include larger, more representative samples of career firefighters. The cros s sectional nature of this study also limits the ability to accurately identify changes in alcohol use over time. Findings from this study suggest alcohol consumption represents a noteworthy health behavior among career firefighters. Further investigations addressing reasons for alcohol use and abuse among firefighters are warranted. Additionally, the current study along with subsequent research can provide salient information necessary for the development and testing of tailored interventions aimed at redu cing firefighter alcohol consumption.

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25 Table 2 1. Participant characteristics Demographic N Percent Sex Male 151 84.8 Female 8 4.5 Race White 142 79.8 Non White 15 8.4 Hours of Sleep: Off Duty 6 or less 75 42.1 7 or more 82 46.1 Hours of Sleep: On Duty 6 or less 140 78.7 7 or more 18 10.1 Diagnosis of Sleep Disorder Yes 17 9.6 No 141 79.2 Exercise Status Exerciser 152 85.4 Non exerciser 11 6.2 Work Status Active duty 140 78.7 Light duty 19 10.7 Smokeless Tobacco Use Yes 32 18 No 128 71.9 Smoking Status Smoker 12 6.7 Non smoker 149 83.7 Drinking Frequency Never 19 10.7 Monthly or less 44 24.7 2 4 times a month 43 24.2 2 3 times a week 37 20.8 4 or more times a week 13 7.3 AUDIT C Score Mean SD Overall 4.11 2.476 Males 4.16 2.508 Female 3.5 1.761

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26 CHAPTER 3 ASSESSING THE ALCOHOL ACTIVITY ASSOCIATION AMONG A SAMPLE OF CAREER FIREFIGHTERS Background While the harmful effects of alcohol consumption are well established (Nelson et al., 2009; Wechsler et a l., 1995c ) ironically, superior health has been observed among drinkers compared to non drinkers (Green & Polen, 2001; Bridevaux et al., 2004). While the exac t relationship and mediating factors of alcohol consumption and positive health outcomes are currently unknown, recent research highlights physical activity as a plausible explanation (Piazza & Barry, 2012) Across all age classifications (i.e. youth, col lege students, general adult population, and older adults), scholarly investigations have consistently documented a positive relationship between physical activity level and alcohol consumption (Piazza & Barry, 2012), a relationship ous alcohol Furthermore, results suggest a dose response relationship between alcohol consumption and physical activity level. While prospective studies are needed, current published literature suggests t hat as drinking increases, so does physical activity. The alcohol activity association has not previously been investigated among career firefighters. Given the physically intense nature of the job and subsequent fitness recommendations for employees (Inte rnational Association of Fire Chiefs, 2008), along with previous studies reporting high rates of alcohol consumption within the occupation (Haddock et al., 2012; Carey et al., 2011), it seems logical to examine the alcohol activity association among firefi ghters. Hence, the purpose of this study is to assess the association between alcohol consumption and physical activity level among a sample of career firefighters. Based on previous

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27 literature, I hypothesi ze that alcohol consumption will have a positive linear association with physical activity. Material & Methods This study was approved by the University of Florida Institutional Review Board. Participants were recruited from a convenience sample of career firefighters who work for a county fire and rescu e service in North Central Florida. This fire department provides both medical and fire rescue to approximately 250,000 people within 969 square miles (United States Census Bureau, 2012). Data on self report alcohol consumption and exercise behaviors was collected using a self administered health assessment survey. Firefighters wishing to participate in the study accessed the survey through a secure, online employee portal. Consent was given prior to beginning the survey. Survey duration was approximately 10 15 minutes, and participants were assured that all responses would remain anonymous. Survey Items Alcohol consumption Three items taken from the AUDIT C (Bush et al., 1998) were used to assess drinking status, drinking frequency, and AUDIT C score. The AUDIT C is a screening tool used to identify hazardous drinking, as well as individuals with active alcohol use disorders. Items included: a) How often do you have a drink containing alcohol? [never, monthly or less, 2 4 times a month, 2 3 times a week, 4 or more times a week], b) How many drinks do you have on a typical day when you are drinking? [1 2 drinks, 3 4 drinks, 5 6 drinks, 7 9 drinks, 10+ drinks], and c) How often do you have 6 or more drinks on one occasion? [never, less than monthly, monthly, weekly, daily or almost daily]. Respondents were informed that one drink is equivalent to a 12 ounce beer, a 5 ounce glass of wine, or a drink with one shot of liquor. While the

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28 AUDIT C has not been previously administered among firefighters, valid and re liable data has been shown among a variety of other populations (Bradley et al., 2007; Frank et al., 2008; Rumpf et al., 2003; Dawson et al., 2005). Physical activity/exercise Measures for exercise included status, frequency (times per week), duration ( minutes per session), and type (aerobic or strength). Items were drawn from the BRFSS and Godin Leisure Time Exercise Questionnaire (LTEQ) (Godin & Shephard, 1985). While the BRFSS has not previously been used to assess exercise among firefighters, data ha s been shown to be valid and reliable among other populations (Yore et al., 2007; Ainsworth et al., 2006; Brown et al., 2004; Evenson et al., 2004). The LTEQ has been used among firefighters, but reliability and validity were not established (Tamers et al. 2011). Still, the LTEQ has been shown to produce valid and reliable data among other populations (Sallis, 1991; Sallis et al., 1993; Jacobs et al., 1993; McIntyre & Rhodes, 2009). Study Variables Drinking status The variable drinking status included responses for AUDIT C score AUDIT C score was calculated according to stand ard scoring procedures (Bush et al., 1998). Values range from 0 to 12, with a score of 7 or more for men, and 5 or more for women, indicating hazarding drinking behavior (DeMartini & Carey, 2012).

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29 Exercise status The variable exercise status was drawn from Typical weekly exercise In or der to determine typical weekly exercise, a composite variable was created from frequency and duration of each type of exercise. Response options for frequency were coded as follows: 1 = 1 time per week, 2 = twice per week, 3 = 3 times per week, 4 = 4 or m ore times per week. Response options for duration were coded: 1 = 30 minutes or less, 2 = less than an hour but more than 30 minutes, 3 = one hour, 4 = more than an hour. The coded values for frequency and duration were then multiplied together to get a se parate score for aerobic exercise and strength exercise. The scores for aerobic and strength exercise were then added together to determine the variable of interest, typical weekly exercise, with scores ranging from 0 to 32. Control variables Control variables included sex and race. Due to low frequencies for non White races, the Age was omitted as a control due to the low frequency of responses (n = 69). Statistical Analysis Statistical a nalyses were carried out using Predictive Analytics SoftWare Version 21. Descriptive statistics were used to assess drinking status, AUDIT C score, exercise status, and typical weekly exercise. Exploratory data analysis was used to ensure all assumptions w ere met. Hierarchical multiple linear regression was used to assess the ability of AUDIT C score to predict the dependent variable, typical weekly exercise, while controlling for sex and race. For

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30 the analysis, only AUDIT C score was entered into Block 1 Block 2 added the control variables sex and race. Results The final sample size included 160 career firefighters. The majority were White (79.8%) and male (84.8%), who, on average, had worked as a firefighter for 14.3 ( 8.8) years. The mean age (n = 69 ) was 37.5 ( 9.2) years Descriptive statistics were used to assess drinking status, drinking frequency and exercise status (See Table 3 1). Overall, a majority of the sample exercised (85.4%), with a mean typical weekly exercise score of 12.5 ( 7.5). L ikewise, 89.3% of the sample drank, with an average AUDIT C score of 4.11 ( 2.5). For the regression analysis, both models were statistically significant. For model 1, AUDIT C score explained 6% of the variance in typical weekly exercise [F (1, 103) = 6.5 5, p = .012]. In model 2, the control measures, race and sex, explained an additional 1.9% of the variance in typical weekly exercise [F (3, 101) = 2.88, p = .04]. However, only AUDIT C score was a statistically significant predictor (B = 0.78, p = .009), indicating that, for each unit increase in AUDIT C score, typical weekly exer cise decreased 0.78. See Table 3 2 for complete regression results. Discussion This is the first study to assess the alcohol activity association among career firefighters. When controlling for sex and race, findings suggest an inverse relationship between alcohol consumption (as measured by AUDIT C score) and physical activity (as measured by total weekly exercise) among career firefighters, in that, as drinking level increases, physical activity decreases. Results run contrary to the initial hypothesis and also contradict previous scientific literature showing a positive linear relationship between alcohol and physical activity across varying age groups.

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31 One plausible explanati on for this finding stems from the sample characteristics. While a majority (85.4%) of the sample reported exercising, the mean total weekly exercise score was approximately 12 out of a maximum score of 32. This indicates that, although they exercised, the average level of exercise (based on frequency and duration) among this group of firefighters was rather low, thus, resulting in the inverse alcohol activity relationship. Furthermore, considering the body composition and fitness findings from Study 3 (see Chapter 4), where 43.7% of the sample was obese and 13.1% overweight based on body fat percentage, in addition to obesity being associated with subpar fitness, it seems logical to suspect that this group of firefighters is not partaking in an appropriate amount of physical activity. Another explanation for the reported inverse alcohol activity association relates to how physical activity was measured. Previous studies assessing the alcohol activity association (see Piazza & Barry, 2012) use measures for p hysical activity encompassing frequency, duration, and intensity of exercise. For this study, the total weekly exercise score was based only on duration and frequency. Thus, it is possible the more complete measures used in other studies provides a more a ccurate picture of physical activity level, and therefore, influences the significance and direction of the alcohol activity association. It is important to note, this study is not without limitations. First, the measures used to examine physical activity level were void of intensity, providing an incomplete assessment of this variable. Additionally, the categorical response options for frequency and duration of exercise limited analysis capabilities and provided a rather vague interpretation of actual lev els of exercise (compared to results using a continuous measure for frequency and duration). This study is also limited by the use of self report data, as participants may not have responded honestly or accurately. To minimize the likelihood of inaccurate responses, all information was

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32 kept anonymous, and only instruments previously shown to result in valid and reliable data were used. Another limitation stemmed from the use of a convenience sample. Hence, the sample was rather homogenous, lacking variabil ity in demographics as well as drinking and exercise behaviors. Thus, results may not be representative of, or generalizable to, the overall population of career firefighters within the United States. Findings from this study contribute to the current bod y of scientific literature, and suggest firefighters represent a unique population with which to study the alcohol activity association. Althoug h an inverse relationship was i dentified, further investigations are warranted. Specifically, future studies sho uld focus on acquiring a more diverse sample of career firefighters based on demographics (i.e. age, race, size of department, geographic location) and health behaviors. Specific attention should also be given to the measures used for physical activity and alcohol consumption, ensuring an accurate depiction of each variable is provided, along with opportunities for robust statistical analyses. Lastly, once the alcohol activity association is established within this occupation, further studies should address why the association exists and what factors serve as primary contributors.

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33 Table 3 1. Participant characteristics Demographic N Percent Sex Male 151 84.8 Female 8 4.5 Race White 142 79.8 Non White 15 8.4 Exercise status Exerciser 152 85.4 Non exerciser 11 6.2 Drinking frequency Never 19 10.7 Monthly or less 44 24.7 2 4 times a month 43 24.2 2 3 times a week 37 20.8 4 or more times a week 13 7.3 Table 3 2 Linear regression predicting AUDIT C score Model B SE B t p 1 Variable Constant 15.55 1.39 11.19 0.0 00 AUDIT C score .742 0. 29 .244 2.558 0.0 12 R 2 .060 F 6.55 .012 2 Variable 9.97 4.10 2.43 0.0 17 Constant .780 0. 291 .257 2.679 0.00 9 AUDIT C score 2.164 2.447 0.0 85 0.885 0. 378 Race 3.974 3.287 0. 116 1.209 0. 229 Sex 9.97 4.10 2.43 0.0 17 R 2 .075 F 2.88 .040

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34 CHAPTER 4 BODY MASS INDEX VERSUS PERCENT BODY FAT AS AN INDICATOR OF OVERWEIGHT/OBESITY AND PHYSICAL FITNESS AMONG CAREER FIREFIGHTERS Background Excess adiposity is associated with increased risk of diabetes, hypertension, heart disease, and several types of cancer (Pi Sunyer, 2002). Considering the number of deleterious health consequences associated with overfatness, in addition to the growing pe rcentage of obese adults in America (35.7% from 2009 2010; Centers for Disease Control and Prevention, 2011), it is no surprise the United States has set forth mandates to increase the proportion of adults at a healthy weight (Objective NWS 8) and reduce t he proportion of adults who are obese (Objective NWS 9; U.S. Department of Health & Human Services 2010). The standard measure of overweight and obesity recommended for individual use and clinical practice (Seidell et al., 2001; Ricciardi & Talbot, 2007) is body mass index (BMI). BMI overfatness (National Institutes of Health, n.d.a.). However, concern over the accuracy of BMI in estimating adiposity has risen, considering the inability of BMI to discern between lean versus adipose tissue. While BMI is an accepted measure of adiposity in large scale epidemiological studies among the general adult population, research has highlighted a severe diagnostic inaccuracy of BMI based on age (Gallagher et al., 1996; Rankinen et al., 1999) sex (Gallagher et al., 1996; Rankinen et al., 1999), ethnicity (Fernandez et al., 2003; Pan et al., 2004), and athletic status (Ode et al., 2007; Nevill et al., 2006). Specifically r egard ing athletic status, BMI has high sensitivity (accurately identifies obes ity among those who are in fact obese) but low specificity ( classifies those who are not obese as obese) among athletic populations (Ode et al., 2007 ) Because athletes tend to have h igher amounts of lean muscle mass compared to the general population (from whom BMI cut points were established), this discrepancy is likely due to the

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35 inability of BMI to differentiate between lean and adipose tissue. In other words, these athletes may ha ve higher body mass but are not overfat. The National Institutes of Health (n.d.b) states Considering the intense nature of the occupation, it is recommended that firefighters maintain optimal levels of physical fitness, often achieved by increasing levels of exercise (International Association of Fire Chiefs, 2008). Based on the recommended fitness level s and high intensity nature of the job, it is likely firefighters would possess a more muscular build compared to the general population. Therefore, according to the N ational Institutes of Health recommendation, BMI may not be an accurate assessment of ove rweight/obesity among the firefighting occupation. To date, only two studies have assessed the accuracy of BMI versus body fat percentage in determining overweightness among firefighters (Jitnarin et al., 2013; Poston et al., 2011a). Jitnarin et al. (2013 ) used a sample of 293 male career and volunteer firefighters, and body fat the study was limited by a) a lack of female firefighter participants, b) only asses sing percentages. Poston et al. (2011a) also used a sample of male career and volunteer firefighters (n = 677) and only assessed the accuracy of BMI in predicting obe sity, not overweightness, based on body fat percentage. The study by Poston et al. (2011a) is also the only study to assess differences in physical fitness based on obesity status. However, this study did not use a comprehensive assessment of physical fitn ess, as muscular endurance tests were not included. In addition, as opposed to estimating VO 2max using submaximal or maximal quantitative aerobic

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36 capacity tests, an estimate of VO 2max was calculated based on subjective, self report exercise habits. A primary aim of this study is to assess the concurrent validity of BMI and percent body fat as an indicator of body composition. In addition, this study also seeks to identify differences in physical fitness levels based on adiposity status (i.e. non overwe ight/obese, overweight (but not obese), and obese) as estimated by BMI or measured by body fat percentage. To account for previous limitations in the literature, BMI and percent body fat categories for overweightness and obesity will be compared among a s ample including both male and female firefighters. Additionally, muscular endurance tests will be included to form a comprehensive assessment of physical fitness and an objective estimate of VO 2max will be used to measure aerobic capacity. Material & Me thods This study was approved by the University of Florida Institutional Review Board. A convenience sample of career firefighters was recruited from a department located in North Central Florida. This fire department provides both medical and fire rescue services to a county of approximately 250,000 people within 969 square miles (United States Census Bureau, 2012). All firefighters within the department were recruited for participation. Data collection included a comprehensive battery of physical fitness tests that were administered by firefighter peer fitness trainers. One firefighter peer fitness trainer was assigned to each participant and responsible for administering all fitness assessments to that participant. Each of these firefighter peer fitness trainers completed a week long certification, including hands on learning of fitness assessments This type of training has been used in previous research collaborations with firefighters (Delisle et al., 2013) To ensure confidence, knowledge, and skill t owards administering the assessments, an in service training with all firefighter peer fitness trainers

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37 occurred one week prior to fitness assessment data collection. In addition, a n exercise physiologist supervised administration and completion of all fi tness testing. Study Measures Blood pressure, resting heart rate, height, weight, and body composition (using bioelectrical impedance analysis) were assessed prior to fitness testing. Specific fitness tests are listed below in order of completion, as recommended by the American Colleg e of Sports Medicine (2014), and follow protocols recommended by the Wellness Fitness Initiative ( WFI ) Cardiovascular fitness Cardiovascular fitness was measured using a submaximal treadmill test following the Bruce protocol. For those (n = 2) with muscu loskeletal limitations, a submaximal stepmill test was used following the protocol recommended by the Fire Service Joint Labor Management WFI. Equipment included the True Fitness M30 model treadmill (True Fitness: St. Louis, MO), Stairmaster 7000PT (Stairm aster: Vancouver, WA), and Polar FS2c heart rate monitor (Polar Electro: Kempele, Finland). Standard calculations from the ACSM (for treadmill) and WFI (for 2max ). Muscular str ength Three tests were used to assess muscular strength: hand grip dynamometer, static arm strength (bicep curl), and static leg strength (dead lift). To measure grip strength, the (Hand Grip Dynamometer Model 78011; Lafayette Instrument Company; Lafayette, IN), ensuring that the dynamometer fit snugly in the first proximal interphalangeal joint. With the dynamometer dial with elbows adducted and flexed at a 90 angle. The participant was to squeeze the dynamometer with maximum force for approximately 3 seconds. Upon releasing their grip, the needle measurement was recorded.

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38 Three trials were completed on each hand, alterna ting hands between trials. The highest score for each hand was recorded as the final score. The Jackson Strength Evaluation System Model 32628CTL (Lafayette Instrument Company: Lafayette, IN), which has been used previously among firefighters (Poston et a l., 2011a), was used with a bicep curl bar (for static arm) and v grip handlebar (for static leg) to measure muscular strength. Following the WFI protocol, the participant stood upon a level and secure dynamometer base plate, with a chain and bar attached. For the static arm test, the participant stood erect with knees straight and elbows bent at a 90 angle in the sagittal plane (traditional bicep curl form). With the participant gripping the bar, the chain was adjusted to a taut position. The participant was instructed to ease into the isometric contraction, without moving the arms, shrugging shoulders, or arching the back, and hold for a maximum of 3 seconds. For the static leg strength test, the participant stood erect with knees straight on the dynamom eter base plate. The chain attached to the base plate was adjusted so the inside edge of the bottom cross member of the v grip handlebar was at the top of the patella. Once the chain was taut and secure, the participant was instructed to flex at the knees and hips in order to reach the handlebar. Holding the bar, looking straight ahead with neck in the neutral position, the participant was to fully extend arms, maintain a neutral back, and ease into the isometric leg contraction without bending at the wai st, rounding the back, or flexing the arms. A 30 second rest period occurred between each of three 3 trials for both the arm and leg strength tests. The maximum force exerted out of 3 trials was recorded as the final score. Muscular endurance T wo tests of muscular endurance included the prone static plank and maximum push up test. For the prone static plank, the participant was instructed to lay prone on a mat, keeping upper body elevated and supported by the elbows. The stopwatch began when th e participant

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39 raised their hips and legs off the floor, supporting the body on forearms and toes. The participant was to hold this position for the maximum amount of time possible, with the test terminated if a) the participant failed to maintain straight body alignment from the shoulder to hip, knee and ankle after 2 verbal warnings, or b) the participant returned to a prone position with hips and legs resting on the floor. Time was recorded in seconds. For the push up test, the participant was to perform the maximum number of standard push ups (on hands and toes with back in neutral position) in a two minute time frame to the cadence of a metronome set at 80 beats per minute (80 push up maximum). The test was terminated if the participant a) reached 80 pu sh ups, b) performed three consecutive incorrect push ups, or c) failed to maintain continuous motion with the metronome cadence. The highest number of successfully completed push ups was recorded as the final score. Lower back and hamstring flexibility The sit and reach test was conducted to measure lower back and hamstring flexibility (Figure Finder Flex Tester; Novel Products Inc.: Rockton, IL). With shoes removed, the participant was instructed to sit on the floor, with legs together and fully extend ed so the feet sat flat against the sit and reach box. With arms fully extended in front of the body, and one hand over the other, the participant was to exhale and use a slow, fluid movement to stretch forward, bend at the waist, and push the measuring de vice as far as possible with the tip of their middle fingers. The best of 3 trials was recorded as the final score (in centimeters). Body composition BMI (kg/m 2 ) was used as an estimate of overall body fatness, and calculated based on height and weight m classifications (National Institutes of Health, n.d.a.): underweight (BMI <18.5), normal (BMI

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40 18.5 24.9), overweight (BMI 25 29.9), obese I (BMI 30 34.9), obese II (BMI 35 39.9), and extre me obesity/obese III (BMI > 40). Body fat percentage was measured using bioelectrical impedance analysis (Tanita Body Composition Analyzer Model TBF 300A; Tanita Coporation of America, Inc.: Arlington Heights, IL). BIA has been recommended as a valid asse ssment of body composition, and shown just as accurate and precise in determining percent fat as skinfold, densitometry, and air displacement plethysmography, and dual energy X ray absorptiometry (Rubiano et al., 2000; Kushner et al., 1990; Jackson et al., 1988; Houtkooper et al., 1996; Segal et al., 1988; Biaggi et al., 1999; Boneva Asiova & Boyanov, 2008). Classifications for normal and overweight adiposity were taken from the American College of Sports Medicine ( ACSM, 2014) due to the specificity of rang es based on age and sex. Because the ACSM does not include body fat percentages indicating obesity, the American ACE, 2013) obesity classifications were used (male: body fat > 25%; female: body fat > 32%). Table 4 1 provides the ACSM recommended percent body fat. Overweightness was categorized as body fat percentage that exceeded the ACSM recommendations but was lower than the ACE cut offs for obesity. Statistical Analysis To assess the concurrent validity of BMI as a diagnostic tool for overweight and obesity, receiver operating characteristics (ROC) curves were created. Area under the curve (AUC) was generated to identify sensitivity and specificity of BMI in predicting a) obesity, and b) overweightness, without the presence of obes ity. Multivariate analysis of variance (MANOVA) was used to determine differences in fitness levels based on overweightness or obesity, as determined by body fat percentage or BMI. The dependent variable included a composite of scores from the physical fi tness tests (e.g.

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41 VO 2max static arm curl, static leg press, push ups, plank, hand dynamometer [sum of right and left scores], and sit and reach). Two MANOVA models were analyzed with the independent variable adiposity status (non overweight/obese, overwei ght but not obese, and obese) categorized by body fat percentage (model 1) or BMI (model 2). Tests for outliers (univariate and multivariate), normality (Mahalanobis distances), linearity (matrix of scatterplots), multicollinearity (correlation matrix), eq variance violation of homogeneity of variance Lambda. For any v .025 was used for follow up analyses. Upon statistically significant results from the MANOVA, follow up ANOVA with Tukey honest significant difference was conducted to determine group differences based on the statistically significant fitness tests. When determining between group effects, Bonferroni adjustment was applied to reduce the chance of Type I error. An alpha of .05 was divided by the number of statistically significant fitness tests and this new alpha was used to determine statistically significant p values for the ANOVA. In the case homogeneity of variance for the ANOVA was violated, Brown Forsythe was used to determine significance of the F value. Results Participant c haracteristics are outlined in Table 4 2. Overall, the sample (n = 177) was comprised primarily of males (n = 168; 95%) with a mean age of 39 years ( 9.3). Body composition classifications based on BMI and body fat are presented in Table 4 3. The majority of participants were considered obese (n = 80; 45%) or overweight but not obese (n = 76; 43%) based on BMI classifications. Based on body fat percentage, 13% of participants were

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42 overweight but not obese, while 44% were obese. Table 4 4 provides average f itness test scores among all firefighters sampled. body fat percentage), the AUC was .9 ( .024; p = .000; 95% CI [.854, .947]), indicating high sensitivity and specificity (Kumar & Indrayan, 2011) The AUC for BMI in determining overweightness (without the presence of obesity) was .778 ( .054; p = .000; 95% CI [.672, .884]), indicating fair sensitivity and specificity (Kumar & Indrayan, 2011) Results indicated a statis tically significant difference in fitness level based on adiposity eta squared = .258]. Statistically significant between subjects effects were observed for V O 2 max [F (2, 165) = 25.988, p = .000 partial eta square =.24], push ups [F (2, 165) = 36.466, p = .000 partial eta square =.307], plank time [F (2, 165) = 19.455, p = .000 partial eta square =.191], and sit and reach [F (2, 165) = 13.609, p = .000 partial eta square =.142]. Follow up analyses revealed statistically significant mean differences in VO 2max between non overweight/obese and obese participants [M = 6.84 1.01, p = .000] and between overweight but not obese and obese participants [M = 5. 72 1.51, p = .000]. Similarly, non overweight/obese and overweight but not obese participants completed, on average, a higher number of push ups compared to those who were obese [M = 11.73 1.39, p = .000; M = 9.79 2.06, p = .000, respectively]. Non o verweight/obese participants also scored higher, on average, on plank time [M = 55.65 8.68, p = .000] and sit and reach [M = 6.91 1.40, p = .000] compared to obese participants. A statistically significant difference in fitness level based on adiposity status when using the previous model, statistically significant between subjects d ifferences were observed on

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43 VO 2max [F (2, 166) = 13.452, p = .000, partial eta square =.139], push ups [F (2, 166) = 13.515, p = .000 partial eta square =.14], plank time [F (2, 166) = 9.709, p = .000 partial eta square =.105], and sit and reach [F (2, 166) = 8.028, p = .000, partial eta square =.088]. Participants who were overweight but not obese scored higher, on average, on VO 2max [M = 5.6832 1.04, p = .000] and sit and reach [M = 5.542 1.42, p = .000] compared to obese participants. Participan ts who were not overweight/obese and overweight but not obese completed, on average, a higher number of push ups [M = 7.087 2.32, p = .002; M = 7.87 1.53, p = .000, respectively] and a longer plank time [M = 40.03 13.85, p = .003; M = 39.82 9.11, p = .000, respectively] compared to obese participants. Discussion Results of this study suggest BMI represents an appropriate diagnostic tool when determining obesity among firefighters but lacks predictive ability in identifying those at risk for obesi ty Thus, BMI should be used with discretion when determining overweightness (or obesity risk) among firefighters Based on the frequencies for classifications by body fat percentage and BMI, it appears that BMI overestimates overweightness but is accurate at estimating obesity. This is evidenced by the discrepancy in percentages of overweight and obese individuals when comparing classification based on BMI versus body fat percentage. The majority of participants were considered obese (n = 80; 45%) or overw eight but not obese (n = 76; 43%) based on BMI classifications. Based on body fat percentage, 13% of participants were overweight but not obese, while 44% were obese. This is also evidenced by the AUC when assessing the ability of BMI to predict overweight ness. Thus, there is a large discrepancy when identifying individuals who are overweight but not obese when using BMI compared to body fat percentage. Therefore, BMI does not appear to be a useful diagnostic tool in assessing overweightness among firefight ers.

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44 When assessing fitness levels, results were the same regardless of using BMI or body fat percentage to classify obese individuals or overweight but not obese individuals. Findings indicated significant differences among four indicators of physical f itness (e.g. VO 2max push ups, plank time, and sit and reach) for non obese versus obese individuals, while no significant differences were observed between non overweight versus overweight but not obese individuals. The findings of this study are cause fo r concern, especially considering the number of negative health outcomes associated with poor body composition and physical fitness. Cardiac events are the number one cause of fatality among firefighters, accounting for 45% of all on duty deaths (Fahy, 200 5). Consequently, research has shown cardiorespiratory fitness (as measured by VO 2max ) is a particularly salient health indicator (Donovan et al., 2009; Davis et al., 2002) and that low cardiorespiratory fitness is associated with increased cardiovascular disease risk among firefighters (Baur et al., 2011). Thus, decrements in VO 2max among obese firefighters represents cause for concern considering the increased risk of on duty cardiovascular events that may result in death. Research has also highlighted a n increased incidence of injury among firefighters with poorer body composition. Among a sample of 347 career firefighters, those who were obese (BMI > 30) were 5.2 times more likely to suffer a musculoskeletal injury compared to their normal weight (BMI 1 8.5 24.9) counterparts (Jahnke et al., 2013). In a similar study among 478 career male firefighters, each unit increase in BMI corresponded with a 9% increase in absenteeism due to injury (Poston et al., 2011b). Decrements in physical fitness are also ass ociated with injury complaints, where increased aerobic fitness and strength are associated with decreased incidence of injury among firefighters (Beaton et al., 2002; Rodriguez &

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45 Eldridge, 2003). Because injury and decreased fitness levels are likely to h inder job performance, considerable attention should be given to these factors specifically among obese firefighters. While this study adds to current literature, it is not without limitations. The use of a convenience sample of career firefighters limits the ability to generalize findings outside of those who were studied. Thus, future investigations should include larger, more representative samples of career firefighters. While air displacement plethysmography and dual energy X ray absorptiometry may be considered the gold standards for assessing body composition, financial and feasibility purposes did not allow for body composition measurement using such equipment. Additionally, considering the technical limitations of obtaining consistent skinfold meas urements across observers (even with standardized training; Kuczmarski, 1996), bioelectrical impedance analysis was used to assess body composition due to the quickness and ease of use. Bioelectrical impedance analysis, including use of the specific brand and model used in this study (Poston et al., 2011a; Ozcelik et al., 2004; Tunay et al., 2009; Gimenez Palop et al., 2005), has been used to measure body fat percentage in multiple scientific studies (Poston et al., 2011a; Romero Corral et al., 2008; Tunay et al., 2009; Ozcelik et al., 2004; Gimenez Palop et al., 2005). Among other physical fitness and health measures, BMI is used as the standard for entry into firefighting as it is quick, non invasive, and cost effective (Gledhill & Jamnik, 1992; Gallaghe r et al., 2000; Prentice & Jebb, 2001). Based on the findings of this study, body fat percentage should be used in place of BMI for assessment among entry level and veteran firefighters, as it offers a more accurate depiction of body composition. In additi on, methods of measurement for body fat percentage, such as BIA and skinfold, are still quick and relatively cheap.

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46 estimated 80% of fire departments neglect to incor porate basic health and fitness programs (National Institute of Standards and Technology, 2004). Considering that body composition and increased fitness directly relate to improved performance within this occupation (Henderson et al., 2007), public health and fire service efforts should seek to enhance overall health and physical functioning of firefighters. Specifically, recommendations for off duty exercise, as well as mandates for on duty workouts, should be incorporated into interventions aimed at impro ving fitness levels and body composition. Likewise, interventions should focus on the importance of comprehensive fitness training, as opposed to emphasis solely on strength or aerobic exercise (Rhea et al., 2004).

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47 Table 4 1 ACSM recommendations for per cent body fat Age 20 29 30 39 40 49 50 59 60+ Female 16 24% 17 25% 19 28% 22 31% 22 33% Male 7 17% 12 21% 14 23% 16 24% 17 25% Table 4 2 Participant characteristics N Percent Sex Male 168 94.9 Female 9 5.1 BMI classification Normal 21 11.9 Overweight 76 42.9 Class I Obese 55 31.1 Class II Obese 20 11.3 Class III Obese 5 2.8 Age (years) N Mean SD Overall 177 38.97 9.314 Male 168 38.76 9.35 Female 9 42.89 7.99 Body Mass Index (kg/m 2 ) 177 29.75 4.66 Male 168 29.8 4.68 Female 9 28.8 4.49 Body Fat (%) 176 23.56 9.81 Male 167 22.89 9.55 Female 9 35.9 5.62 Systolic Blood Pressure (mmHg) 177 126.2 13.04 Diastolic Blood Pressure (mmHg) 177 78.8 8.89 Resting Heart Rate (bpm) 177 75.96 11.68

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48 Table 4 3. Body composition classification by body fat versus BMI Classification by Frequency Percentage Body fat Non overweight/obese 76 43.2 Overweight, not obese 23 13.1 Obese 77 43.7 BMI Non overweight/obese 21 11.9 Overweight, not obese 76 43.1 Obese 80 45.0 Table 4 4. Average fitness test scores Fitness test N Mean SD Cardiovascular fitness (ml/kg/min) 177 40.7 7.03 Hand grip dynamometer (lbs; right and left) 176 216.7 45.1 Static arm (lbs) 174 108.7 25.9 Static leg (lbs) 176 338.3 81.4 Static plank (sec) 174 98.1 59.4 Push up 173 23.4 10.1 Sit and reach (cm) 175 34.5 9.2

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49 CHAPTER 5 CONCLUSIONS Overall, results from this research suggest firefighters represent a salient population among which to study alcohol use, physical activity, and fitness. Rates of alcohol consumption within this occupation are higher compared to the general population, as well as college students. While the majority of firefighters reported parta king in exercise, the overall level of exercise (based on average frequency and duration) was low. Considering exercise plays a key factor in maintaining a lean body composition, it was not surprising to identify over half of the firefighter sample as over weight or obese. Furthermore, those identified as obese had subpar fitness levels compared to non obese firefighters. These findings are particularly alarming considering the potential detriments to job performance and safety. For instance, firefighters wh o drink on duty or report for duty still intoxicated are likely to suffer from cognitive and motor deficits that would impair their ability to respond to rescue calls. This not only places themselves at increased risk for injury and death, but also compris es the safety of their colleagues and the individuals being rescued. Insufficient levels of physical activity, and subsequent low levels of physical may not be able to withstand the physical stress encountered on duty, once again, placing themselves, their colleagues, and the public at increased risk for harm. As a whole, this research can be used to increase public health and occupational awareness specific ally towards firefighter drinking and fitness. Because the job is highly dependent on alertness, readiness, and physical functioning, primary goals for nationwide adoption of policies and mandates should include a) decreasing overall alcohol consumption (a s well as consumption in close time proximity to shift work), in addition to b) establishing fit for duty standards. In the meantime, individual fire departments should take the initiative to monitor

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50 fitness levels among employees with annual or bi annual fitness testing, followed by tailored interventions for those employees deemed unfit for duty. For instance, peer fitness trainers can be paired with unfit firefighters to provide a) education related to the importance of a healthy lifestyle, b) goal setti ng techniques, c) exercise and wellness programming (e.g. weekly workout schedules, healthy eating menus), and d) accountability. Incentives can also be offered for improvement and maintenance of physical fitness and health biomarkers (e.g. blood pressure, cholesterol). For instance, firefighters could be given a monetary bonus for passing quarterly health screenings or completing annual fitness testing with satisfactory scores. Fire services may also establish monthly or quarterly workshops and employee se minars focused on a variety of health behaviors. For instance, a nutritionist and/or alcohol abuse counselor may speak with employees on the physiological effects of alcohol and how lingering effects of consumption can impair job safety and performance. F irefighters should also learn typical warning signs of intoxication in order to address potential issues with intoxicated colleagues reporting for duty. Similarly, the use of wellness coaches or peer fitness counselors can assist firefighters in establishi ng and maintaining active lifestyles off duty, in order to improve overall health, body composition, and physical fitness. It is important to note, several limitations are inherent throughout this work. The use of self report data for alcohol consumption and exercise behavior increases the likelihood that participants may not have responded honestly or accurately. To inhibit the influence of this limitation on findings, a) participants were ensured that all data would be kept anonymous, and b) only instru ments previously shown to result in valid and reliable data were used. In addition, recruiting a convenience sample of firefighters resulted in low frequencies for sex and race/ethnicity, specifically female and non White participants. While the demograph ic

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51 characteristics of the sample included proportions representative of the overall population of firefighters (Bureau of Labor Statistics, 2011), the small number of females and non White participants may still decrease the ability to generalize study fin dings. The use of firefighter peer fitness trainers to administer fitness tests might have resulted in inconsistencies across trainers, thereby potentially decreasing validity and reliability of the results. To decrease the likelihood of this limitation, all peer fitness trainers were certified through a week long workshop, re assessed for proper test administration one week prior to department wide testing, and supervised by student assistants from the University of Florida and a mastered exercise physiol ogist. The rigor of the research, specifically for Study 2 (Chapter 3), was inhibited by incomplete measures of physical activity, as intensity was not assessed. While frequency and duration are key components of physical activity and can provide a glimps e at overall activity level, an accurate depiction (to facilitate comparison to national recommendations) cannot be calculated without knowing intensity. Additionally, items used to assess frequency and duration of exercise were vague in wording and respon se options, further inhibiting the accuracy in measuring overall activity level, as well as limiting options for statistical analysis. Throughout the course of conducting this research, multiple lessons were learned. First, in academic/research collaborat ions, all involved parties must work to ensure the highest standard of rigor. Maintaining open lines of communication, establishing accountability, and double feasibly and efficiently. Second, when using self report measures, always pilot your materials. For survey instruments, this will ensure proper logistics, skip patterns, etc., and also identify potential limitations in administering the survey to your populatio n of interest. Third, special considerations must be taken into account when working in academic community partnerships.

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52 As researchers/academicians, we are programmed to uphold high scientific rigor. We study the literature and devote our time to crafting research to answer questions in the best way possible. However, when working with individuals outside the realms of research and academia, we must population of int erest. Case in point, among firefighters recruited for participation in this research, high levels of apprehension ensued due to fear that survey responses and fitness data would be reported to the fire department administration, potentially placing them a t risk of losing their jobs or being demoted. Therefore, as a researcher, it was my responsibility to clearly communicate to the firefighters that all data would be kept confidential and only accessible to the research team at the University of Florida, no t fire department administration. Still, many of the firefighters voiced their concern and stated that, although responses were anonymous, the demographic questions asked in the survey (e.g. age, rank, station number, years of service) could potentially be used to identify specific employees. Therefore, in an attempt to further decrease apprehension, as well as increase participation and decrease the likelihood of skipped/missing responses, select questions were omitted from the draft survey. Participation rates were high; however, as noted in Chapters 2 and 3, less than half of respondents indicated their age. Thus, while precautions were taken, the research was still affected by the amount of missing data, as age could no longer be used as a covariate/cont rol. Although the aforementioned factors created obstacles throughout the course of this work, the wisdom gained as a result of these lessons will enhance judgment and rigor with future research and involvement in collaborations. Additionally, working in c lose proximity to the population of interest provided key insights that otherwise would not have been identified.

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53 Research findings will be disseminated through four primary methods. Manuscript submission and scholarly presentations are two avenues that w ill focus on communication of results to researchers, academicians, and practitioners. Each study (Chapters 2 4) will be submitted for publication. While the final outlets have not been determined, Occupational Medicine Addictive Behaviors, Preventive Me dicine the Journal of Obesity and Medicine and Science in Sport and Exercise are journals currently under consideration. Presentation of research findings will also be given at national, state, and/or local conferences. Focusing on the population of int erest, results will be compiled into a brief summary to be presented as a newsletter posted on Target Solutions for all ACFR firefighters to read. Lastly, a meeting will be scheduled with ACFR and county administration to discuss results and future plans. At this meeting, a research presentation will be given on research findings, as well as suggestions for future research, health behavior programming, and fire service policy.

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64 BIOGRAPHICAL SKETCH In the s pring of 2014, Anna received her doctoral degree in Health and Human Performance. She majored in health education and behavior and also served as a research assistant.