Obesity has become a modern-day blight and emergency medical technicians (EMTs) and paramedics are not immune. Over the past several years, obesity has been growing in prevalence affecting all groups of people, some more than others. With the coronavirus pandemic, life was brought to a standstill and people found themselves more sedentary than ever; fitness centers were closed, work was brought home, and overall movement was decreased. Such circumstances create the perfect mixture for an increase in the already high prevalence of obesity.
While many jobs are more sedentary in nature, EMS is the opposite in which a certain level of fitness is needed. Our job requires lifting of patients or heavy bags and working in stressful situations; it is imperative that EMS professionals take care of their bodies to prevent injuries and burnout while on the job. To better understand obesity, a normal range should be defined for men and women. Below is a chart that defines ranges for BMI relative to weight and height.
We can see that between 25-29.9 is classified as overweight and obesity is classified with an obesity above 30.1 While this chart and others like it define the “normal,” there are certain outliers. The person who is of athletic build from weightlifting for instance might be classified as obese in a simple height and weight chart, but obviously they are not.
As one gains more weight, their chance of severe health problems increases such as heart disease, high blood pressure, diabetes and cancer of certain types.2 Given that EMS is one of the frontline workers for this pandemic, severe illness from COVID also increases.
Obesity can be thought of as the imbalance between energy used and calories ingested.2 As fat accumulates on any individual, a hormone known as leptin is seen to increase as it is secreted by adipose cells.3 This hormone, leptin, is the appetite suppressing hormone and it essentially tells the body that its energy stores are adequate enough.4 A correlation can be found between the more fat stores an individual has and the circulating leptin in their blood.5 In studies involving rats it was found that when they were administered leptin doses, the rats exhibited leptin resistance which can also be seen in obese individuals leading to lack of appetite suppression.4
Obesity and Diabetes
As the obesity crisis continues to grow in the United States, diabetes has been shown to grow alongside it. For the sake of discussion diabetes represents a disorder in which the uptake of glucose is affected;6 Type 2 is most commonly linked to the obesity epidemic.6 While the connection has been under investigation, both Type 2 diabetes and obesity have been linked to insulin resistance. In Type 2 diabetes we see that there is a blend between low insulin production from the beta cells on the pancreas and insulin resistance throughout the body.7
Typically, due to poor diet, large amounts of sugar enters the body after food consumption which triggers the pancreas to release insulin to manage blood sugar.8 As time goes on these cells slowly become resistant to this hormone8 much like the leptin resistance pathway. With proper diet, exercise, medication, reducing chronic stress and adequate sleep diabetes can be effectively managed.
A proper diet and exercise eliminates the risk of consuming excess calories which leads to the elevated glucose level thereby preventing too much stress on the insulin release and absorption pathway. Medication improves sensitivity to insulin. Finally reducing stress can directly lower blood sugar; when stressed the body releases cortisol triggering the liver to produce more glucose.9 At the end of the day the best treatment is to prevent.
Obesity and Heart Disease
Heart disease is the leading cause of death in the United States. According to the CDC, nearly 650,000 deaths can be attributed to heart disease. Obesity can be directly tied to impacting the cardiovascular system; research has shown that there is a role in the development in coronary artery disease and atherosclerosis which is the depositing of fatty plaques in artery walls.10 The addition of plaque increases the workload of the heart by increasing the work or force needed to propagate blood throughout the body. Over time, myocardial structure is altered and leads to impaired function.10
In atherosclerosis, there are several commonalities with obesity, namely activation of inflammatory pathways, increased blood pressure and altered lipid counts.11 Due to secretion of pro inflammatory cytokines, localized inflammation occurs and ultimately leads to plaque growth.12 Should there be a stronger inflammatory response, the risk of plaque rupture or clot formation increases significantly contributing to infarct or ischemia.12
Hypertension is also related onset of heart disease. Poor diets can lead to water retention due to excess salts, osmolarity principles show water will follow salt and be retained causing elevated blood pressure.13 Moreover, due to hypertension artery elasticity decreases over time; this is crucial because reduced elasticity inhibits adequate blood flow which increases the likelihood of infarct or ischemia.14 If a heart is already taxed and undergoes stressful and exercise intensive circumstances, there is again a higher chance to infarct.
Obesity is also directly related to heart failure, a condition where the myocardium does not pump blood adequately enough. If the resistance to pump blood is high, the heart will try to compensate and can lead to left ventricle hypertrophy.15 In this state of hypertrophy, the wall elasticity is also reduced and greater pressure is needed to fill the ventricle for systemic circulation.15
Obesity and EMS
EMS is a stressful occupation and takes its toll on all providers. Research has shown that more than 75% of emergency responder recruits are overweight or obese.16 This is a concerning statistic due to the demands this field of work of work requires. As stated before, obesity is a primary risk factor for developing heart disease, diabetes and other health afflictions.
Emergency responders all have knowledge on these conditions and in fact routinely treat these types of patients, so why are so many providers not in the best shape. To understand this phenomenon, we need to understand a typical schedule for emergency responders. Long and variable shifts (days or nights), limited time between calls, stressful work environments, and sleep deprivation influence unhealthy behaviors in EMS. In Pittsburgh, EMS rooms are primarily stocked with unhealthy food options with few offering healthy choices. The EMS rooms are classified as the best by EMS providers are the ones that offer greatest number of unhealthy snacks such as chips, ice cream and soda. After a call, there is only a short amount of time before the crew has to be back in service, this leads little to no time for a provider search out a better option at a hospital cafeteria.
In other cases, ambulances are stationed around their area of service, and often parked next to some sort of fast food restaurant. Again, due to time constraints, fast food is the primary option because if a call comes in the provider must leave immediately. Snacks and fast food that are commonly chosen are heavy in fats, sugar, processed carbs, and lacking in fiber which leaves the body wanting more and not as satiated as a nutritionally complete meal.
This leads to the consumption of excess calories and eventually weight gain. Not only does obesity cause life threatening problems, but it also causes non-life threatening issues including back pain which can severely shorten a providers’ time in EMS. A strong correlation was found between weight and lower back pain; as weight accumulates on the body the natural curvature of the spine is shifted, obesity move the pelvis forward and cause excessive spine curvature.
This adds additional pressure on the back muscles to compensate for the weight.6 EMS as a profession can be lifting intensive and any measures should be taken in place to protect the providers back such as maintaining healthy weight and strength, and proper lifting form.
Many EMS providers are sleep deprived with up to 50% suffering from fatigue.17 Whether it is due to long hours on the job, uncertain shift times (altering from days to nights) sleep is a rare commodity in EMS. While it is recommended for adults to have anywhere between 7-9 hours of sleep per night,18 that can be unreasonable especially if a provider is working overnight. Calls disrupt continuous rest and further compound the problems of sleep deprivation.
Studies have found that lack of sleep is linked to obesity because of increased appetite for caloric dense foods. One explanation points to the circulating hormones that are responsible for hunger, ghrelin and leptin. Research has shown that increased ghrelin and decreased leptin levels were present in a sleep deprived body.5
What Can Be Done
In a perfect world, one can easily just say eat healthy and sleep more to EMS providers, but the problem is much more challenging than that. Due to time and high stress how can someone reasonably stay healthy while working? One solution is to plan in advance, during off days you can meal prep for the week and choose healthy options to bring to work. Rather than eating fast food, you can eat a meal from home which can be much healthier.
If the receiving facility offers EMS break rooms, opt for the healthy option such as fruit or a sandwich over ice cream or chips. This can leave the provider fuller for a longer period. Substitute water for soda, this can dramatically limit the amount of sugar ingested. If there is no choice than to go to a fast-food restaurant, pick the healthiest option available, most offer salads or low carb selections. If available while on shift, try to get some sort of exercise in to stay in shape in between down time. Employers have also realized that being overweight can affect performance and on-the-job injuries.
Many employers now offer a Healthy Weight Program that incentivizes the employee to maintain a normal weight or enroll in a weight reduction program. Finally, make sure to get as much sleep as possible before coming into work. Most shift workers find that getting on a set sleeping schedule and maintaining it even on off days makes for feeling better rested. At the end of the day, it is much easier said than done, however effort will always be needed to stay in shape and keep healthy.
- File:Body mass index chart.svg [Internet]. Wikimedia Commons. [cited 2021Apr13]. Available from: https://commons.wikimedia.org/wiki/File:Body_mass_index_chart.svg
- Obesity [Internet]. [cited 2021Apr6]. Available from: https://www.bhf.org.uk/informationsupport/risk-factors/your-weight-and-heart-disease
- Leptin [Internet]. [cited 2021Apr6]. Available from: https://www.sciencedirect.com/topics/neuroscience/leptin
- Alan A Saber MD. Bariatric surgery [Internet]. 2021 [cited 2021Apr6]. Available from: https://emedicine.medscape.com/article/197081-overview#a2
- Gruzdeva O, Borodkina D, Uchasova E, Dyleva Y, Barbarash O. Leptin resistance: Underlying mechanisms and diagnosis [Internet]. 2019 [cited 2021Apr6]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354688/
- Al-Goblan AS, Al-Alfi MA, Khan MZ. Mechanism linking diabetes mellitus and obesity [Internet]. 2014 [cited 2021Apr6]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4259868/
- Type 2 diabetes [Internet]. 2019 [cited 2021Apr6]. Available from: https://www.cdc.gov/diabetes/basics/type2.html
- Insulin resistance and diabetes [Internet]. 2019 [cited 2021Apr6]. Available from: https://www.cdc.gov/diabetes/basics/insulin-resistance.html
- Cortisol linked to higher blood sugar in patients with type 2 diabetes [Internet]. [cited 2021Apr6]. Available from: https://www.pharmacytimes.com/view/cortisol-linked-to-higher-blood-sugar-in-patients-with-type-2-diabetes
- Csige I, Ujvárosy D, Szabó Z, Lőrincz I, Paragh G, Harangi M, et al. The impact of obesity on the cardiovascular system [Internet]. 2018 [cited 2021Apr6]. Available from: https://www.hindawi.com/journals/jdr/2018/3407306/
- Yoo HJ, Choi KM. Adipokines as a NOVEL link between obesity and atherosclerosis [Internet]. 2014 [cited 2021Apr6]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4058739/#idm140347562837488title
- C; HGKRAKS-N. Inflammation and atherosclerosis [Internet]. [cited 2021Apr6]. Available from: https://pubmed.ncbi.nlm.nih.gov/18039117/
- Hall JE, John E. Hall From the Departments of Physiology and Biophysics (J.E.H., Carmo JMdo, Jussara M. do Carmo From the Departments of Physiology and Biophysics (J.E.H., Silva AAda, Alexandre A. da Silva From the Departments of Physiology and Biophysics (J.E.H., et al. Obesity-induced hypertension [Internet]. 2015 [cited 2021Apr6]. Available from: https://www.ahajournals.org/doi/full/10.1161/CIRCRESAHA.116.305697
- High blood pressure symptoms and causes [Internet]. 2020 [cited 2021Apr6]. Available from: https://www.cdc.gov/bloodpressure/about.htm
- Left ventricular hypertrophy [Internet]. 2020 [cited 2021Apr6]. Available from: https://www.mayoclinic.org/diseases-conditions/left-ventricular-hypertrophy/symptoms-causes/syc-20374314
- DiGravio GM. Researchers find majority of fire and ambulance recruits overweight or obese [Internet]. 2009 [cited 2021Apr6]. Available from: https://news.harvard.edu/gazette/story/2009/03/researchers-find-majority-of-fire-and-ambulance-recruits-overweight-or-obese/
- Wilson D. An EMS Emergency: Sleep deprivation and fatigue [Internet]. 2015 [cited 2021Apr6]. Available from: https://www.emsworld.com/article/12135723/an-ems-emergency-sleep-deprivation-and-fatigue
- Can overeating cause sleep disturbances? [Internet]. 2020 [cited 2021Apr6]. Available from: https://www.sleepfoundation.org/physical-health/sleep-and-overeating