Navigating Occupational Challenges: First Responders’ Perspectives on Dietary Intake and Behavior

Introduction : This study aimed to investigate first responders' dietary beliefs, habits, and food choices. Methods: Cross-sectional data were obtained from 21 first responders via validated questionnaires. Data were analyzed using SPSS version 29 software. Results : 21 first responders, including 13 law enforcement officers and eight firefighters, participated (age=37.8±10.0 years, height=180.8±6.5 cm, body mass=94.3±13.1 kg, and body mass index=28.9±4.5 kg/m2). Most participants reported being very willing (n=8, 39.1%) or willing (n=7, 33.3%) to change their eating habits. Barriers to healthy eating included busy lifestyles (n=19, 95%), irregular working hours (n=13, 65%), and willpower (n=10, 50%). Participants also placed importance on several food choice factors. Conclusions : First responders reported valuing healthy eating. However, unique barriers challenge them despite their willingness to improve their habits. These data may aid further investigation of healthy eating strategies in these populations.

Dietary modification has been shown to impact health outcomes positively [20][21][22] , and a recent comprehensive review highlighted the need for more research, as little is known about nutrient intake or specific dietary habits and patterns of first responders 1 .Only a few studies have directly explored dietary patterns and habits among firefighters [23][24][25] and LEOs 26 .Soteriades et al. 25 noted that, among U.S. firefighters, CVD events on duty are strongly connected with poor lifestyle choices (e.g., suboptimal dietary habits).Further, Yang et al. 23 found that most career U.S. firefighters were classified as overweight (body mass index [BMI] = 25-29 kg/m 2 ) or obese (BMI ≥30 kg/m 2 ) and desired to learn more about healthy eating 23 .In addition, less than 30% of the surveyed firefighters reported following a specific diet, with the majority (≈75%) open to receiving dietary education 23 .Christodoulou et al. 24 found that the Mediterranean diet was associated with more favorable cardiometabolic health outcomes compared to the standard American diet among a cohort of U.S. firefighters.Lastly, MacKenzie-Shalders and colleagues 26 assessed the factors and barriers influencing a cohort of 159 U.S. LEOs.They found that 80% of respondents were willing to change their dietary habits to be healthier.In addition, 91% and 80% of respondents placed high importance on consuming nutritious foods and foods high in vitamins and minerals, which highlighted that the cohort was knowledgeable about healthy eating 26 .Importantly, 60% and 41% of respondents noted that a busy lifestyle and irregular working hours were barriers to healthy eating practices 26 .It is important to note that first responder occupational demands vary greatly depending on specific job responsibilities, secondary jobs, stress exposure, and exercise training habits 1 .As such, the barriers to healthy eating may vary among the first responders.Therefore, research is warranted to understand these potential differences better.Taken together, these data suggest that certain cohorts of first responders are knowledgeable of healthy eating; however, there are barriers related to the busy lifestyles of the occupation that hinder their abilities to implement and adhere to healthy eating practices.
First responders need pragmatic lifestyle modifications that promote health while improving occupational performance and readiness.The first step in initiating change in an individual's diet is to identify their current patterns, habits, and barriers hindering healthy eating 1 .In addition, identifying the challenges they face could help implement wellness policies, set up supportive diet environments, encourage healthier eating, and better target the needs of specific fire and police departments 1 .This study aimed to investigate the dietary beliefs, habits, and food choices among a cohort of U.S. first responders and explore differences (if any) between firefighters and LEOs.The specific aims were to 1) explore the self-reported barriers toward optimizing one's diet, 2) report perceptions of factors influencing food choices, and 3) perform a rapid assessment of diet quality and willingness to change via a brief set of surveys suitable for administering among first responders [27][28][29] .

Participants and Experimental Design
Participants were sampled from local fire and police departments in the south-central U.S. region.Inclusion criteria were that the participants: 1) must have been between 18 and 60 years old at the time of the study, 2) were current first responders within the south-central U.S. region, and 3) provided voluntary, informed consent to participate.If the potential participants did not meet these inclusion criteria, they were excluded from the study.It is important to note that recruitment for this study was conducted through email and social media flyer advertisements, as well as through the investigator's professional networks, across the south-central U.S. region -particularly across the states of Texas and Oklahoma.Self-reported demographic data were collected via an online survey, including height and weight, physical activity (i.e., resistance and endurance-based training frequency), and descriptive dietary data (i.e., current diet, who prepares food/meals).This study was carried out in full accordance with the declaration of Helsinki.All experimental produces subsequently described were approved by the Institutional Review Board of Texas A&M University (IRB-0649M) and the Bond University Human Research Ethics Committee (KM03179).
A cross-sectional survey study was conducted in 2021 (between the months of August and December), which evaluated data from local fire and police departments in urban and rural metropolitan areas in the south-central U.S. region.Interested participants were able to access the online survey via the provided link in the advertisements, where the informed consent portion of the online survey was provided.Once the individuals provided informed consent, they were prompted to click "next" and began responding to the online questionnaires, including the Rapid Eating Assessment for Participants, Shortened Version (REAP-S), the Food Choice Questionnaire (FCQ), and the Perceived Barriers to Health Eating.These questionnaires are designed to assess perceived barriers toward eating a healthy diet, individual attitudes and beliefs toward factors that influence dietary intakes, and dietary quality and willingness to change current eating habits/patterns.If the participants could not complete the surveys in one sitting, they were allowed to save their respondent progress and return later to complete the entire study.

Dietary Questionnaires
Data were obtained using validated surveys administered online via a Qualtrics survey link, which included the REAP-S, the FCQ, and the Perceived Barriers to Health Eating questionnaires.Previously reported internal consistency coefficient (ICC) data among various populations for the surveys are as follows: 1) the REAP-S has been reported to have an ICC of 0.71 30 ; 2) the FCQ has been reported to have an ICC between 0.781-0.918across all factors 31 ; and 3) the Perceived Barriers to Health Eating has been reported to have an ICC between 0.73-0.77.These questionaries have been previously published [27][28][29]32,33 and utilized to assess dietary intake and patterns among a similar population 26,34 . The RAP-S is a 13-item questionnaire developed at the Albert Einstein College of Medicine of Yeshiva University 35,36 .The questions of REAP-S focus on how often participants consume various foods or dietary patterns during the average week and are categorized as follows: 'usually/often,' 'sometimes,' or 'rarely/never.' The FQ is a questionnaire used to measure multidimensional factors regarding food choice at the individual level and through factor analysis of health, mood, sensory appeal, price, weight control, convenience, familiarity, and ethical concern 29 .This 36-item questionnaire uses a five-point Likert Scale for responses ranging from 'not important' (score of 1) to 'very important'(score of 5).The FCQ has been utilized among various populations 35,[37][38][39] .Lastly, the Perceived Barriers to Health Eating questionnaire 27 , which contains a list of 22 possible barriers to engaging in healthier dietary behaviors, was utilized.Experts in attitudinal research developed this questionnaire to identify perceived barriers to healthy diets 27 . The srvey scores indicate diet quality while noting participants' willingness to change eating habits, reflecting readiness to change.

Statistical Analysis
The questionnaire data were analyzed using IBM ® Version 29 SPSS ® statistical analysis software (IBM Corp., Armonk, NY, USA).Previous work from our group based the sample size on the total number of LEOs within a large metropolitan facility 26,34 , while the present study sample size was based on the total number of respondents to the online survey.As such, the investigators sent out several email and social advertisements in an effort to increase respondent rate.A Shapiro-Wilk Test was used to assess normality for all continuous variables.Demographic data were analyzed for differences between the firefighters and LEOs via independent samples t-tests, while effect sizes were calculated via Cohen's d (i.e., small effect, d=0.2; medium effect, d=0.5; and large effect, d=0.8) 40 .For the demographic data, the probability of type I errors (p-level) was set at 0.05 or less, while statistical tendencies were also noted when p-values were between 0.05 and 0.10.All survey categorical data are reported as frequencies (n) and total percentages.Chi-square analysis was used to determine group independence for categorical variables (p<0.05) or a Fisher's exact test (two-sided) when results had ≥20% of cells with an expected count of less than five.Significant differences and associations were defined as p<0.05 a priori.

Demographics
Twenty-one first responders (n=13 LEOs; n=8 firefighters) from the south-central U.S. participated in the crosssectional survey study, and the participant characteristics can be viewed in Table 1.Trends were noted for weight (p=0.066,d=0.878) and BMI (p=0.052,d=0.931), wherein firefighters weighed more (101.0±15.2 vs. 90.2±10.2kg) and had greater BMIs (31.3±5.7 vs. 27.4±2.9kg/m 2 ) than the LEOs.No demographic differences were found between first responder groups for resistance and aerobic training, nor in their reported diets (data shown in the supplementary file, Table 1).

Food Choice Questionnaire Results
The FCQ results can be viewed in Table 2.The majority of participants placed importance or high importance on the following FCQ factors: keeps me healthy, is nutritious, is easily available, keeps me awake and alert, tastes good, helps control my weight, is high in protein, and makes me feel good.Secondary chi-square analysis revealed differences between firefighters and LEOs for the following FCQ factors: 'is low in calories' (p=0.046,ꭓ2=7.956) and 'is low in fat' (p=0.050,ꭓ2=7.798).The LEOs placed low importance on 'is low in calories' and 'is low in fat' compared to the firefighters (Table 2).

Rapid Eating Assessment for Participants Results
The REAP-S results can be viewed in Table 3.When asked, 'How willing are you to make changes in your eating habits in order to be healthier?',most participants reported being very willing (39.1%, n=8), followed by willing (33.3%, n=7), neutral (14.3%, n=3), not very willing (9.5%, n=2), and not willing at all (4.8%, n=1) to make changes, wherein a chisquare analysis revealed no differences between the firefighters and LEOs (Table 3).

Perceived Barriers to Healthy Eating Results
Table 4 shows the results for perceived barriers to healthy eating.The main barriers reported include a busy lifestyle, irregular working hours, and willpower.The secondary chi-square analysis did not reveal any differences between firefighters and LEOs (Table 4).3 (15%) Healthy food is more awkward to carry from shops 0 (0%) Too great a change from my current diet 1 (5%) Feeling conspicuous amongst others 0 (0%) Data are presented as frequencies (n) and total percentages.One participant did not fill out this questionnaire section and is not included in the analysis.

Discussion
The present study provides insight into the factors influencing dietary habits and patterns, food choices, and perceived barriers to healthy eating among a cohort of first responders from a south-central region of the U.S. In particular, 72.4% of the first responders expressed willingness to change their current dietary habits (very willing: 39.1% and willing: 33.3%) to be healthier.However, despite the desire to change, several key perceived barriers were reported, such as busy lifestyle (95%), irregular working hours (65%), and willpower (50%), among others.Importantly, these perceived barriers did not differ between the two subgroups of first responders (firefighters and LEOs).Several food choice factors were also identified, including 'keeps me healthy, 'is nutritious,' and 'is high in protein,' which influenced the foods eaten and diet(s) followed by the first responders (i.e., high protein diet).These data are critical to understanding first responder nutrition and how to best serve these populations with precision nutrition guidance (e.g., increasing protein intake or modulating dietary deficiencies).
The REAP-S questionnaire results demonstrate that first responders are willing to change their dietary habits, which mirrors other reports among LEOs 26,34 .In a study of U.S. first responders, MacKenzie-Shalders et al. 34 found that when asked whether participants would like to change what they eat, reserve police officers (60%), custody assistants (55%), and sworn deputies (34%) all agreed that they would like to change what they eat as opposed to disagreed (5%, 8% and 17% respectively).Furthermore, responses to the REAP-S reported in other work by MacKenzie-Shalders et al. 26 found that 94% of police officers were willing (14%) or very willing (80%) to change their eating habits to be healthier.Unfortunately, many LEOs believe their occupations are not conducive to healthy eating 41 .The findings of this study partly support this supposition.
For example, in the current study, the main barrier to healthy eating identified was a busy lifestyle (95%), exemplified by the sporadic occupation and the fact that many first responders have multiple jobs 42 .The first responders also reported irregular working hours (65%) and willpower (50%) as the other two main perceived barriers to healthy eating.Unfortunately, the nature of both firefighting and policing is unpredictable, and these first responders may be subject to multiple response/emergency calls throughout their shifts.The firefighters' dietary behaviors will likely be impacted by location (i.e., city, town, rural, or urban region), time, accessibility, and convenience, and over time, these dietary behaviors can become habits that persist and contribute to chronic disease risk 43 .Similarly, LEOs are subject to shift work and mandatory overtime.As a result, these first responders may struggle to adhere to conventional mealtimes.To this end, importance and high importance were placed on the FCQ factor 'is easily available' (40% and 45%, respectively) and 'is easy to prepare' (40% and 25%, respectively), supporting the notion that first responder will likely opt for convenience given the constraints of their occupation (i.e., shift work, overtime, sporadic response/emergency call volumes).While the cohort of first responders value nutritious foods (94.7%), there are factors beyond nutritional knowledge that may prevent dietary behavioral change, and further research is warranted to help unmask these factors.
One potential solution can be found in the work by Sotos-Prieto and colleagues 44 , who assessed a cohort of U.S. firefighters via telephone interviews.In their study, the authors identified that incumbent and recruit firefighters valued culture within the firehouse to foster better nutrition.In other words, having peer support and a food environment with healthy food options may offer a solution to some of the perceived barriers.Furthermore, participants of the Sotos-Prieto et al. 44 study reported a need for more education on proper nutrition as another key barrier.Contrasting this, only 15% of the first responders in this study reported 'not knowing enough about healthy eating' as a perceived barrier, suggesting they believe that their knowledge is not a barrier to healthy eating.For example, when asked if they 'skip breakfast' or 'eat four or more meals from sit-down or take-out restaurants,' most participants reported rarely/never (52.38% and 55.55%, respectively).A majority also reported consuming more than 7.5 ounces from protein sources daily.It is also worth noting that the participants reported they tend to undereat fruits and vegetables (i.e., consuming less than two servings).While these responses were self-reported, previous research has demonstrated that an individual's perceived diet quality parallels their actual diet quality 45 .Taken together, the results of the REAP-S questionnaire highlight that the first responders are aware of their shortcomings regarding healthy eating.Considering the findings of other qualitative work, first responders and practitioners working with these populations need to ensure their job site (i.e., police or fire station) fosters strong peer support and provides easy access to healthier food options (e.g., fruits and vegetables in the kitchen or breakroom).
There are no clear nutritional standards or guidelines for first responders 1 .General energy and macronutrient provisions and timing are currently considered to mirror that of the general public; however, it is clear that first responders face specific physically and psychologically demanding conditions that augment their nutritional needs.In addition, eating environments for firefighters and LEOs may differ based on the sense of community among stations within departments.For instance, firefighters may share meals or eat together when on shift, which may be an important factor for nutritional intervention and dietary adherence (i.e., implementing healthy eating that can be shared among the group rather than just the individual).In comparison, LEOS may not dine together as often, thus, dietary interventions must take this into consideration.Furthermore, care should also be given to the heightened risk of CVD among first responders 1 .It is also important to note that first responders are susceptible to various sedentary-related health conditions (e.g., diabetes) 1 .Interestingly, nearly 50% of the cohort of first responders in the present study reported engaging in 0-1 session(s) per week of aerobic training, while 33.3% and 28.6% of first responders reported engaging in 0-1 and 2 session(s) per week, respectively.These results suggest that most of the first responders in this study did not meet the healthy adult exercise guidelines, 30 minutes five times per week, recommended by the American College of Sports Medicine 46 .While this may not be indicative of the exercise training habits of other U.S. first responders 47,48 , it is important to note, as there are data to suggest first responders are largely sedentary [49][50][51][52] and that they become less fit throughout their careers 53 .Considering the intense physical demands of these occupations (e.g., requirements to lift, carry, or drag heavy objects/people 5,6,[8][9][10]54 , it is important for first responders to engage in regular resistance and aerobic training, which may increase their nutritional demands. This study has several limitations.First, only first responders within the south-central region of the U.S. were surveyed, and these results may not be indicative of other regions/areas across the U.S. or other countries.Therefore, these results should be interpreted with caution when generalizing to other groups of first responders from different regions or countries, as many of these dietary habits, patterns, and barriers will be influenced by the culture and surrounding environment of the station and department.Second, this study included a relatively small sample size.The survey questionnaires were shared via a Qualtrics survey link, which may be detected as phishing or spam filters by departmental email filters and may not have reached some employee emails.Furthermore, there were time constraints on obtaining a high response rate due to agency availability.Indeed, further work is needed to survey other regions across the U.S., which will likely increase the sample size included in future research.Lastly, the questionnaire answers are all self-reported; therefore, the continuous data (i.e., BMI, body weight) may not be accurate.However, the work by Dawes et al. 55 does suggest that self-reported height, weight, and derived BMI in these populations are accurate.A notable strength of this study was that the questionnaires included were validated and provided a broad description of the respondents' dietary habits, patterns, and perceived barriers.

Conclusions
Research suggests that first responders are willing to change their current dietary habits to be healthier; however, they face barriers (e.g., busy lifestyles and irregular working hours) that limit their ability to make changes.Of note, first responders do appear to have some knowledge of healthy eating habits (i.e., increasing dietary protein, not skipping breakfast).Thus, interventions to improve their healthy eating habits will likely benefit this population.First responders in this study reported falling short regarding fruit and vegetable consumption and meeting weekly exercise recommendations; thus, interventions should consider increasing fruit and vegetable consumption and enablers to increase daily exercise.Further, barriers within the respective stations, departments, cities, and regions influence the dietary habits of first responders (i.e., culture, peer support, food environment), and more research is needed to understand better what these barriers are and how to overcome them best.Lastly, minimal differences were noted (i.e., the FCQ factors 'is low in calories' and 'is low in fat') between the firefighters and LEOs.These first responder groups likely have similar barriers and habits.First responders and practitioners should consider these results when gauging their stations or departments' dietary needs in prioritizing healthy eating and better-fueling strategies to combat disease risk and improve occupational health, performance, and readiness.

Table 2 .
Food choice questionnaire results.

Table 3 .
Rapid eating assessment for participants, shortened version results.

Table 4 .
First responders' perceived barriers to healthy eating results.