Risk Factors Requiring Wellness Interventions

The following is an exclusive excerpt from the book NSCA’s Essentials of Tactical Strength and Conditioning, published by Human Kinetics. All text and images provided by Human Kinetics.

Apart from physical conditioning, there is a need for tactical occupations to incorporate wellness programs (75, 79). Wellness programs are known to decrease fiscal costs for organizations (14), and their importance to tactical athletes extends to post-career longevity and health for veterans. In fact, veterans are known to be at greater risk of illness and disease (both physical and psychological) (42, 93).

Ameliorating risk factors for chronic illnesses and diseases in tactical populations should be a key focus of wellness programs. These risk factors include physical inactivity, stress, tobacco usage, excessive alcohol consumption, sleep disruption, and poor nutritional habits, as will be discussed in this section.

Physical Inactivity

Because fitness is related to morbidity (49), most health authorities recommend performing three or more weekly exercise sessions (i.e., sessions that are designed to achieve a desired outcome and include dedicated training to increase metabolic demands) (33, 49). Although the need for physical exercise is well acknowledged within both the general and tactical populations, tactical athletes face several barriers to participation. Earlier chapters have noted that some tactical occupations are quite sedentary. For example, law enforcement officers and firefighters spend a large amount of time sitting doing desk work, driving, or waiting for emergency calls, with only limited (although demanding) tasks requiring physical activity (3, 67). A further complication is found with older officers as they increase in rank and take on more strategic positions that require even less physical activity (104). This decrease in physical activity associated with occupational role is not restricted to rank and age, however. For example, Australian Army personnel working as staff in a training institution reported that their fitness tended to decrease when they served in training environments as opposed to in their operational units due to the logistical and administrative requirements at the training institution (75).

Other work contexts that affect physical inactivity include shift work and unexpected daily tasks. Shift work can decrease sleep quality and in turn increase fatigue (discussed later in this chapter). In addition, research suggests that shift work has a negative impact on the desire to exercise (47). Likewise, tactical personnel may be less inclined to perform physical exercise at the commencement of a shift if they may be required to perform optimally at any time within the shift. For example, a training session that induces leg fatigue could negatively affect the explosive speed of a tactical officer seeking cover or a firefighter moving rapidly up a staircase in a burning structure. At the end of a shift, fatigue, lethargy, and the allocation of time to other priorities (e.g., family, social obligations) can reduce the desire to perform physical exercise. For example, in a study on interventions to reduce cardiovascular risk in law enforcement officers (94), comments collected as part of a focus group included a police officer stating that, given the high daily workload, “All of a sudden, you are done with your shift and it’s like you don’t want to do much; you just want to crash.”

Stress

It is not surprising that work stress is notable in tactical occupations. Firefighters are exposed to the dangers of fighting unpredictable fires. Soldiers may face an enemy who operates outside any laws of armed conflict. Law enforcement officers could be exposed to shootings, robberies, severe motor vehicle accidents, and, similar to firefighters and military personnel, deceased bodies. In addition, tactical athletes may be required to spend extended periods of time away from their families and personal support systems, which increases occupational stress (13). One study suggested that nearly a quarter of military personnel considered time away from family as causing “a lot” of stress (13). And in a population of firefighters, decreased numbers of personnel in a crew or a given shift increased occupational stress (62).

These occupational stresses have far-reaching consequences for tactical personnel. For example, increased occupational stress in tactical populations has been associated with an increased risk of injury (7) and an increased risk of diseases associated with stress (112). Additionally, maladaptive coping strategies may include other health detractors, such as smoking cigarettes and drinking excessive alcohol (40).

Tobacco Use

Smoking cigarettes and chewing tobacco have long been part of some tactical occupations, notably military and law enforcement, for a variety of cultural reasons. Rates of cigarette smoking have been found to increase in these tactical occupations (92, 101), leading to rates that are higher than in the general population (37). Rates can also differ among tactical populations. For example, the smoking rate is higher in Marines than U.S. Air Force personnel (13). Reasons for this higher rate may include both maladaptive coping behaviors to stress (40) and shift work, which is a known risk factor for smoking in a variety of occupations (53). Even within a given tactical population, rates of tobacco use may vary, with research suggesting that lower ranks are more prone to smoking compared with higher ranks (102).

Because of the widely known health risks of cigarette smoking and community education about them, this trend in tactical populations may be changing. For example, in firefighters, smoking tobacco may now be less common than in the general population (45). The main reasons firefighters give for stopping tobacco use are knowing the end result, improving fitness, and becoming more educated on the risks (85). In addition, the decrease in smoking rates may be due to policy at both the state and local levels, such as the restriction of cigarette smoking as a condition of employment and related presumption laws (85). However, smokeless tobacco still has a higher rate in the U.S. firefighter and military populations than in the civilian population (13, 45). These results may be restricted to U.S. populations because smokeless tobacco is less prevalent in other places, such as Australia, where it is banned (4).

Excessive Alcohol Consumption

Alcohol consumption by tactical athletes can vary from the national average to well above (13, 16, 92). Furthermore, two studies noted that although officers may not drink more frequently than civilians, they tend to consume more drinks in a single session (92). As with cigarette smoking, serving in a tactical occupation may increase alcohol consumption (73), particularly as a coping behavior for stress (40). Also akin to cigarette smoking, rates of excessive alcohol consumption are higher in some tactical occupations (e.g., U.S. Marine Corps and Army personnel) compared with others (e.g., U.S. Navy and Air Force) (13). For example, the trends in binge drinking in the U.S. Department of Defense ranged from 39% in Air Force personnel up to 58% in Marines, while professional firefighter rates were similarly high at 56% (16).

Sleep Disruption

Although individual needs vary, the majority of adults require seven to eight hours of sleep per night (96). Insufficient sleep and an accumulation of sleep loss (or sleep debt) have been associated with reduced quality of life, impaired cognitive function (e.g., reduced reaction times, decreased alertness, impaired concentration), and altered mood states (e.g., decreased emotional control, increased anxiety, increased tension) (43, 96). Furthermore, sleep deprivation can cause people to perceptually disengage from their environment and cease to integrate outside information, have diminished situational awareness, and have impaired judgment (96). Sustained wakefulness for 17 or more hours has been found to decrease cognitive performance to a state equivalent to a blood alcohol content of 0.05% (27). This is concerning given that tactical personnel may be in high-risk situations following periods of limited sleep and thus may be performing with impaired cognitive function. Additionally, research suggests that sleep loss has a cumulative effect. An in-depth study by van Dongen et al. (111) showed that less than eight hours of time in bed led to a progressive increase in sleep debt to the extent where, after 14 days, the subjects performed cognitive tasks at a level similar to people who had not slept for 24 to 48 hours.

Sleep disruption does not just refer to getting three hours of sleep in a night and waking up exhausted. The type of rest must also be considered, especially if the rest occurs while on duty; eight hours of sleep under these circumstances are not the same as eight hours at home. Apart from dozing in a semi-altered state and the impact of communal sleep areas and incidental noise, waking once per night on a consistent basis is enough to disrupt the body’s natural cycles (34). Chronic exposure to these detractors of restful sleep over the course of a career, especially inconsistent sleep patterns with extra shifts and changes in call load, assignment, and alarm type, can desensitize tactical personnel so that they accept chronic fatigue and its effects as normal (28).

Key Point

Although often overlooked, special attention should be given to sleep patterns in tactical populations.

When subjects in the study by van Dongen et al. (111) were asked every two hours how they were feeling, after two days most stated that they had adapted and were not feeling any additional fatigue even when the cumulative impact of sleep loss increased dramatically (as measured by the Stanford Sleepiness Scale). It appears that people may not be able to accurately rate their level of fatigue, nor may they consider the risks associated with fatigue to be important in light of competing priorities. This lack of insight may contribute to attitudes toward sleep loss where lack of sleep is not seen as a risk and rest is not prioritized over competing activities (36). The consequences of this occupational attitude are highlighted throughout history. For example, soldiers manning forward positions have been known to combat their desire to sleep by pulling pins from grenades and holding down the levers (71). More recently, a police officer suffered a serious road accident after driving to court following nearly 35 hours of work (60). As a final consideration, lack of sleep can affect motivation (41), which feeds into a negative cycle compounding the lack of physical activity.

Nutritional Habits

A multitude of factors affect a tactical athlete’s nutritional intake, including shift work, nutrition availability on operations, and so on. Although tactical nutrition is discussed in greater detail in chapters 5 and 6, certain factors related to health and well-being are worth considering here, particularly communal eating and skipping meals. Communal eating increases the transfer of pathogens and subsequent illness. Dirty cookware and cutlery in communal kitchens or sheds in a field are prime examples. In training institutions, food exposure to the elements for extended amounts of time (e.g., over a meal period) and cross-contamination (e.g., sharing a tub of yogurt or carton of milk) can increase the potential for illness (77).

When it comes to good nutritional habits, the tendency to skip breakfast is of notable concern. Breakfast is considered a marker of an appropriate dietary pattern (98) and health quality (8, 69, 100). Missing breakfast may lead to increased obesity (63), increased BMI (19), loss of nutrients that is not regained during the day (69), and reduced mental health (100). An investigation of an officer training unit found that staff members were more likely to miss breakfast than the general population (75). This report also found that, during lunch, many of the staff ate at their desks. Eating lunch at the workplace desk has also been associated with negative health outcomes. For example, sitting at a desk for long periods of time may reduce the amount of daily physical activity. Indirectly, sitting at the desk eating lunch could lead to additional time at the computer, which can increase the risk of repetitive strain injuries (RSIs) (32) and computer vision syndrome (10) and decrease quality of life (50). Interestingly, this culture of eating at the desk may not be related to a lack of facilities. The author noted that one police station had a new kitchen with full cooking facilities and even an enclosed garden that stood empty at lunchtime, with staff eating takeout at their desks and completing reports (75).

Ultimately, poor nutritional habits are prevalent in tactical populations (31, 44, 90). Furthermore, simply making sure healthier food options are available will not lead to optimal nutritional fitness unless personnel make healthy food choices (68). A final consideration lies in the traditional focus in military nutrition on undernutrition. Historically, investigations into soldier nutrition in the military have mainly been concerned with the adverse effects of undernutrition (65); however, an emerging threat to soldier nutrition is overnutrition or overconsumption, resulting in the increased weight concerns (e.g., overweight, obesity) discussed earlier in this chapter (20).

Compounding Effects

Key risk factors associated with chronic illness and disease common in tactical populations have been presented in isolation; however, health and well-being result from a combination of factors. A classic study by Belloc and Breslow (8) identified seven lifestyle habits as the foundation of good health:

1. Moderate exercise two to three times per week (significantly less than today’s recommendation of five days per week at a moderate intensity or three days per week at a vigorous intensity [49])
2. Three meals a day at regular times with no snacking
3. Breakfast every day
4. Seven to eight hours sleep
5. No smoking
6. No alcohol
7. Moderate weight

Furthermore, Belloc and Breslow (8) considered these lifestyle habits to be cumulative, meaning that they are related to one another and compounding in nature. These results are not surprising, given evidence suggesting that missing meals is associated with poor sleep quality (1) or that drinking alcohol and smoking cigarettes are associated with stress (92). Although the works of Belloc and Breslow (8) have been criticized for failing to include stress as a measure of health (114), a paper by Morimoto (70) that includes stress measures (subjective stress and work for ≤9 hours per day) likewise lists moderate exercise two or more times per week, seven to eight hours of sleep per night, and daily breakfast as indicators of health.

Because these risk factors may be compounding, risk reduction strategies have the potential to affect multiple risk factors simultaneously. Thus, the impact of wellness programs can be far reaching in both the general population (104) and in tactical populations (82). The SHIELD (Safety and Health Improvement: Enhancing Law Enforcement Departments) program for police officers (57) serves as an example. Rather than targeting a single behavior, the SHIELD curriculum sessions, conducted for 30 minutes once a week for  12 weeks, focused on daily exercise and nutrition, sleep, stress, heavy alcohol consumption, and tobacco usage (57). Improvement in all of these measures was noted and generally maintained for 24 months, with the multipronged approach considered instrumental in the longevity of positive outcomes (57).

NSCA's Essentials of Tactical Strength and Conditioning is the ideal preparatory guide for those seeking the Tactical Strength and Conditioning Facilitator^® (TSAC-F^®) certification, and a reference for fitness trainers who work with tactical populations such as military, law enforcement, and fire and rescue personnel. The book is available in bookstores everywhere, as well as online at the NSCA Store.