Promoting Healthy Living: Assessing More Effects (PHLAME)

Daily physical activity and appropriate dietary habits have well-established health benefits. Yet most Americans do not exercise regularly or eat diets rich in fruits and vegetables and low in saturated fats. Firefighters, in particular, represent an especially high-risk group with higher rates of obesity, hypertension, and dyslipidemia, as well as certain malignancies and chronic musculoskeletal complaints. Firefighters' cardiovascular risks as a group, combined with the episodic intense physical exertion, extreme heat, and life-threatening situations they face on the job, put them at excessive risk for heart attack. As many as half of all on-the-job deaths among firefighters are the result of a heart attack. While firefighters recognize the increased risk associated with their occupational requirements, previous lifestyle interventions directed at firefighters have been largely unsuccessful.

The PHLAME (Promoting Healthy Living: Assessing More Effects) program explores new ways of promoting heart health among firefighters, including healthy eating habits (e.g., five or more servings of fruits and vegetables each day, less than 30% of calories from fat), regular physical activity, and appropriate body weight. Evaluations of PHLAME have examined and compared two models of behavior change:

1. A peer-led team-centered scripted curriculum that incorporates aspects of social-cognitive theory (e.g., peer bonds, mutual accountability, and shared responsibilities or rewards) as the vehicle for changing members' attitudes and behaviors; and

2. A state-of-the-art, individual-centered intervention that uses counselors skilled in motivational interviewing techniques to help individuals identify their intrinsic motivation and means for change.

For the team-centered curriculum, each shift at the fire station or a self-identified work group becomes a separate team. The designated team leader uses a Team Leaders Manual with explicitly scripted lesson plans to facilitate the eleven 45-minute team sessions. Each session comprises three to six activities. Activities are designed to be interactive, enjoyable, and consistent with principles of adult education. Friendly competition and positive peer pressure among team members and across teams are encouraged. Core activities included nutrition, physical activity, and energy balance while electives can select additional topics from the core topic list. During the sessions, personal goals based on physical, laboratory, and dietary findings, are formulated and discussed. The sessions are implemented weekly, with breaks between certain sessions for longitudinal bridging activities, (e.g. team member tracking grid, which further reinforces the objectives of the program).

Individual-centered motivational interviewing uses a more traditional client-and-provider format. A counselor first meets privately with each firefighter on duty to identify the priorities that influence their behaviors using a values card-sort activity. During the next three meetings, physical, laboratory, and dietary findings are reviewed, and potential health behavior changes were identified. In the fourth meeting, follow-up is negotiated, with the possibility of up to 5 hours of additional in-person or phone contact.

The team-centered curriculum requires eleven 45-minute weekly team sessions administered in clusters over approximately 1 year. The individual-centered motivational interviewing curriculum involves a minimum of four one-on-one meetings, with the possibility of up to 5 hours of additional in-person or phone contact.

The interventions were designed for and evaluated with full-time, fit-for-duty professional firefighters.

The interventions are suitable for implementation in fire stations and work groups (such as those in the Fire Marshall's office).

The team-centered curriculum is provided in a Team Box. It includes the following:

• Team Leader Manual-used by the designated Team Leader. Includes a training section, twelve scripted team sessions and workbook pages for the electives. The manual also contains various index cards, training cards, post-cards used for games or activities.
• Workbooks-used by the team members during the sessions. Includes the twelve session curriculum and workbook pages for the electives.
• Elective Manual-used by the designated Elective Leader. Includes fifteen scripted elective sessions. Manual also includes components used in the elective sessions.
• Fire Fighters Health and Fitness Guide-given to each team member. Contains up-to-date information about nutrition, vitamins, supplements, physical activity, cancer, heart disease, and more.
• Family Manual-includes extra copies of session activities which can be taken home to be completed with families.
• Bag of additional pieces-includes all extra pieces to be used in conjunction with team session activities, e.g. various index cards, training cards, post-cards, and decorative erasers.
• Recipe box-includes healthy recipes incorporating fruits and vegetables.

Team materials cost approximately $25 per firefighter.

The team-centered curriculum is being disseminated as it is designed to be easily exportable and in a format to facilitate its use with high fidelity. The individual-centered, Motivational Interviewing, component is not included.

A randomized design was used to compare the effectiveness of two intervention paradigms to promote healthy eating habits, regular physical activity, and appropriate body weights among full-time, fit-for-duty firefighters. A prospective trial was conducted with 579 male and 20 female firefighters, with a mean age of 41 years (ranging from 20 to 60 years old) and predominantly White (91%). Participants were randomized by station to the team-centered curriculum, one-on-one motivational interviewing, or the control group, which received only their test results with brief explanations and a listing of normal values. Participants were assessed at baseline and 1-year follow-up.

Main outcomes include (1) improved nutrition and healthy dietary behavior, (2) increased physical activity and fitness, (3) decreased weight gain, and (4) increased general well-being. Healthy dietary behavior was a construct made up of seven items: (1) overall rating of diet, (2) generally select healthy food items when eating at restaurants, (3) when I cook I prepare meals that are healthy, (4) intentions to eat low fat, (5) in the last year I have tried to eat more fruits and vegetables, (6) in the past year I have tried to eat less fat, and (7) do you consistently avoid eating high fat foods. A single score was derived by averaging responses to the seven items. Increased general well-being: This score was derived by averaging responses to three items: (1) how would you say your health is, (2) I am as healthy as anybody I know, and (3) my health is excellent.

Key Findings

Compared with participants in the control group, participants in both the team-centered curriculum group and the one-on-one motivational interviewing group experienced statistically significant improvements in healthy dietary behaviors, physical activity and fitness, avoidance of weight gain, and general well-being. Findings for the main targeted outcomes are presented below.

• Improved nutrition and healthy dietary behavior:

  Despite relatively high baseline levels, both intervention groups had statistically significant increases in fruit and vegetable intake, measured as the number of daily servings (baseline: M=5.8 and 5.5, follow-up: M=7.4 and 6.2 for team curriculum and individual counseling, respectively) compared with the control group (baseline: M=5.7, follow-up: M=5.8; team curriculum vs. control group: p<.01, individual counseling vs. control group: p<.05)

  

  Both intervention groups showed statistically significant increases in healthy dietary behavior (baseline: M=4.14 and 3.96, follow-up: M=4.55 and 4.43 for team curriculum and individual counseling, respectively) compared with the control group (baseline: M=3.99, follow-up: M=4.12; p<.005)

  

• Increased physical activity and fitness: Both intervention groups showed statistically significant improvement in the number of sit-ups individuals could complete in 1 minute (baseline: M=36.3 and 34.5, follow-up: M=38.4 and 37.4 for team curriculum and individual counseling, respectively) compared with the control group (baseline: M=35.1, follow-up: M=36.0; p<.05)

  

• Avoidance of weight gain: Participants in both intervention groups gained less weight (body weight at baseline: M=195.7 and 192.7 pounds, follow-up: M=196.6 and 193.9 pounds for team curriculum and individual counseling, respectively) compared with the control group (body weight at baseline: M=196.6 pounds, follow-up: M=200.0 pounds; p<.05)

  

• General well-being improved in both intervention groups, with statistically significant changes (baseline: M=3.59 and 3.65, follow-up: M=3.70 and 3.73 for team curriculum and individual counseling, respectively) compared with the control condition (baseline: M=3.57, follow-up: M=3.51; p<.05)