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Rates of false positives and negatives using BMI-based obesity classification and comparable body fat (BF%) and waist circumference (WC) categories. Obesity Status Types and rates of misclassification
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Obesity is a significant problem affecting United States (US) firefighters. While body mass index (BMI) is widely used to diagnose obesity, its use for this occupational group has raised concerns about validity. We examined rates and types of misclassification of BMI-based obesity status compared to body fat percentage (BF%) and waist circumference...
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[Purpose] The aim of this study was to determine the effects of high-frequency current therapy on the abdominal obesity levels of young women. [Subjects] Twenty-two women with abdominal obesity were randomly allocated to either an experimental group (n 1 = 10) or a control group (n 2 = 12). [Methods] The experimental group subjects received high-fr...
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... Research conducted on BMI accuracy among law enforcement officers and firefighters leans toward under classifying individuals as obese (i.e., misclassified as nonobese, when they are considered to be obese based on body fat percentage (%BF) [5,6] and waist circumference (WC) measurements) [5,7]. In contrast, research conducted in military personnel has revealed strong correlations between BMI and %BF measurements [8]. ...
The prevalence of overweight and obesity among tactical populations is estimated at 70-75%, which may negatively impact health and performance. The relationship between body mass index (BMI) and health and performance is well established among the general population, however literature on such relationships among tactical populations has yet to be reviewed and evaluated. The purpose of this study was to systematically review available literature on the relationship between BMI and health and occupational performance among law enforcement officers (LEO), firefighters, and military personnel. After reviewing the literature, 27 articles were included. Nine studies found BMI was positively associated with cardiovascular disease (CVD) risk factors. Studies involving BMI and cancer were lacking. One study found BMI was positively associated with type 2 diabetes (T2DM) risk. Five studies on occupational/physical performance and twelve studies on injury found a higher BMI was often indicative of decreased performance and increased risk of injury in general, but protective against stress fractures. Overall, higher BMI was often associated with negative health and performance outcomes among tactical populations, especially when beyond the overweight classification. Public health practitioners should focus efforts on improving nutrition and physical activity to promote a healthy BMI among these individuals.
... Both findings are important for anthropometry practice facilitating the choice of proper methods of body fat measurements in young adults. It is well documented that the most commonly used measure of body fat -the body mass index (BMI) expressed as body mass (kg) divided by the height in meters squared, does not provide information concerning fat distribution and in consequence may underestimate health consequences of excessive body fat [26,32,38,42]. It is worth mentioning that some individuals have a normal BMI but have increased percentage of body fat characterizing the term known as "normal weight obesity" (NWO), and present an increased risk of developing metabolic disorders [33]. ...
... Abbreviations: LBM -lean body mass; WC -waist circumference; HC -hip circumference; WHR -waist-to-hip ratio; WHtR -waistto-height ratio; AVI -abdominal volume index; BAI -body adiposity index; RFM -relative fat mass; a P < 0.001 -significantly different vs. females.26.2%) do not determine significant differences in BMI values(23.3 ...
Study aim : Our study was undertaken to analyze agreement between measured body fat and different indices of fatness in students of both sexes and with different physical activity.
Materials and methods : A total of 330 students not engaged in regular physical activity (150 males and 180 females) and 356 students (180 males and 176 females) engaged in regular physical activity due to their study program (5–7 h/week) were recruited. In all participants body adiposity was measured from skinfold thickness. In addition, calculated indices of fatness based on waist (WC) and hip circumference (HC), such as abdominal volume index (AVI), body adiposity index (BAI) and relative fat mass (RFM) were calculated.
Results : The analysis of Bland-Altman plots revealed that agreement between measured and calculated body fat was found for RFM and BAI in sedentary and active men and for BAI in sedentary women, but not for measured body fat and RFM in sedentary women and for RFM and BAI in active women.
Discussion : Our study showed that in young adult Poles of both sexes and with different physical activity, the calculated obesity rates should be used with caution, especially in women, as an indicator of total body fat.
... Most of the studies were more focused on physical fitness, whereas fewer studies investigated the effects of psychological, demographics, lifestyle, and occupational characteristics. The firefighters who have higher age, sleep disorders, high Body Mass Index (BMI), high-risk behaviors (e.g., smoking, alcohol consumption, unhealthy eating habits, and addictions), chronic diseases (e.g., diabetes, hypertension, hypercholesterolemia, metabolic disorders, and cardiovascular and respiratory diseases), low aerobic capacity, low body strength, low experience, low length of service, musculoskeletal disorders, tumors, and those who are female are more prone to occupational injuries (28,(47)(48)(49)(50)(51)(52). Table 2 presents all the indicators extracted from the selected papers. ...
Background: We aimed to identify indicators affecting firefighters’ resilience through a systematic review.
Methods: International electronic databases, including Web of Science, Medline through PubMed, Scopus, Cochrane Library, and Google Scholar, were searched on Dec 23, 2018. The search strategy was developed using main words, including firefighter, resilience, and indicators. Then, the indicators related to firefighters’ resilience were extracted and analyzed using a qualitative synthesis method.
Results: Overall, 7178 unique documents were identified by searching different databases. Then, by screening the title and abstract, 7104 articles were excluded, and only 74 full text papers were critically studied. Finally, 31 full text articles were selected for the analysis. Quality appraisal of included studies done by modified STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) tool. Moreover, 186 indicators and cri-teria were extracted from the included studies and classified into 6 domains and 15 categories.
Conclusion: This study suggests six main domains, including physical health, physical fitness, mental health, life style, job-related competencies, and demographic status, to categorize different indicators of firefighters’ resilience. Building resilience in firefighters requires all these domains to be considered in the assessment, planning, and evaluation processes.
Keywords: Resilience; Safety; Firefighter; Systematic review
... While some feel BMI may be appropriate, other data in this population suggest that BMI fails to appropriately categorize individuals as obese compared to when using BF% and waist circumference [257][258][259]. Additionally, CVD appears to be more prevalent among law enforcement officers, current and retirees, than among the general population (odds ratio = 1.70, 95% confidence interval = 1.03 to 2.79) [260,261]. ...
This position stand aims to provide an evidence-based summary of the energy and nutritional demands of tactical athletes to promote optimal health and performance while keeping in mind the unique challenges faced due to work schedules, job demands, and austere environments. After a critical analysis of the literature, the following nutritional guidelines represent the position of the International Society of Sports Nutrition (ISSN).
GENERAL RECOMMENDATIONS Nutritional considerations should include the provision and timing of adequate calories, macronutrients, and fluid to meet daily needs as well as strategic nutritional supplementation to improve physical, cognitive, and occupational performance outcomes; reduce risk of injury, obesity, and cardiometabolic disease; reduce the potential for a fatal mistake; and promote occupational readiness.
MILITARY RECOMMENDATIONS Energy demands should be met by utilizing the Military Dietary Reference Intakes (MDRIs) established and codified in Army Regulation 40-25. Although research is somewhat limited, military personnel may also benefit from caffeine, creatine monohydrate, essential amino acids, protein, omega-3-fatty acids, beta-alanine, and L-tyrosine supplementation, especially during high-stress conditions.
FIRST RESPONDER RECOMMENDATIONS Specific energy needs are unknown and may vary depending on occupation-specific tasks. It is likely the general caloric intake and macronutrient guidelines for recreational athletes or the Acceptable Macronutrient Distribution Ranges for the general healthy adult population may benefit first responders. Strategies such as implementing wellness policies, setting up supportive food environments, encouraging healthier food systems, and using community resources to offer evidence-based nutrition classes are inexpensive and potentially meaningful ways to improve physical activity and diet habits. The following provides a more detailed overview of the literature and recommendations for these populations.
... Approximately 50% of firefighters are classified as overweight with an additional 25% being classified as obese [12][13][14]. Overweight and obese firefighters are at higher risk of experiencing injury, missing work, suffering from chronic illness, and experiencing a cardiac incident compared to their healthy weight peers [9,13,15,16]. Combined with the lack of physical fitness, overweight and obese firefighters create an even greater level of concern. ...
Background:
Firefighting is a strenuous profession requiring adequate levels of fitness for effective job performance. Providing firefighters with a safe and effective fitness program is essential for optimal performance. The purpose of this project was to examine changes in various parameters of physical fitness and firefighter ability following a 7-week high intensity functional training (HIFT) program.
Methods:
Participants were male firefighter recruits (N = 89; age = 27.1 ± 4.2 years, height = 1.78 ± 0.1 m, BMI = 28.1 ± 4.2) enrolled in a Basic Operations Firefighter Academy. Fitness and firefighting ability (via the Academy Firefighter Challenge) were assessed at Weeks 1 and 7 of the Academy.
Results:
Significant improvements in both fitness and firefighter ability were seen following the HIFT program. Specifically, fitness (BMI, cardiovascular fitness, muscular endurance) improved significantly [Hotelling's T2 = 8.98, F(5, 84) = 150.92, p < 0.001, η2p = 0.90]. Firefighter ability also improved significantly [Hotelling's T2 = 3.95, F(7, 88) = 46.26, p < 0.001, η2p = 0.80].
Conclusions:
Following a 7-week Basic Operations Firefighter Academy that included daily HIFT, significant increases in fitness and firefighting ability were observed. These findings suggest that HIFT appears to be an effective means of improving fitness and firefighting ability in recruit firefighters.
... In a longitudinal study from 2004-2007, 37% of 7904 fire-fighters had dyslipidemia [14]. Like most shift workers, fire-fighters are more likely to eat fast-foods or 'quick' meals with high proportions of fat that adversely affect blood lipid profiles and accelerate the atherosclerotic process [17]. ...
... The current study showed that 45.90% of fire-fighters were obese with high waist circumference measurements that predisposed them to increased cardiovascular events [1,3,4]. Overweight and obese fire-fighters often presented with multiple CAD risk factors, such as prediabetes, hypertension, and hypercholesterolemia [1,11,16,17,22]. Fire-fighters with a high BMI were at increased risk for work-related injuries and disabilities [4]. ...
Background: Cardiovascular disease is a major cause of morbidity and on-duty mortality among fire-fighters. This study investigated the prevalence of coronary artery disease (CAD) risk factors among firefighters in Cape Town, South Africa.
... In this context it seems that more precise and reliable classification of body fat is provided by the American Council on Exercise (ACE), which distinguishes individuals not only with respect to sex but also activity levels [2]. Moreover, its practical use in fatness evaluation was confirmed in studies concerning soldiers and firefighters, i.e. in professions characterized by high physical activity levels [12,16,26]. ...
... such as firefighters and soldiers [6,9,16,19,21,26]. Similarly, a significant discrepancy between body fat and BMI was noted in college students and young athletes [4,12,24,27,30]. ...
Study aim : Numerous data have indicated that body fat stores undergo complicated regulation by genetic and environmental factors, including physical activity. However, the majority of studies did not take into account this aspect of lifestyle in proposed body fat limits. In this context it seems that a more precise and reliable classification of body fat is provided by the American Council on Exercise (ACE), which distinguishes individuals not only with respect to sex but also activity level.
Material and methods : A total of 793 students (312 sedentary and 481 active) volunteered to participate in the study. Among sedentary participants 147 were male and 165 female. Among active subjects 206 were male and 275 were female. Active subjects were engaged in different modes of physical activity according to the study program. In all participants body mass index (BMI) was calculated. In participants with BMI 18.5–24.9 and BMI ≥ 25 body fat was determined using four skinfold measurements. Thereafter participants were classified according to the percentage of body fat using ranges for males and females provided by the American Council on Exercise (ACE) (essential fat, athletes, fitness, average and obese fatness).
Results : None of the sedentary and active males with BMI 18.5–24.9 had high (obese) fat. In contrast, in sedentary males with BMI ≥ 25 16.4% were obese vs. 1.8% of obese active ones. In sedentary females BMI from 18.5 to 24.9 did not exclude obesity, which was found in 16.9% of participants. In sedentary females with BMI ≥ 25 most of the subjects (97.1%) were obese. In contrast, in active females with BMI ≥ 25 a similar percentage of participants had average and obese fat (53.3% and 46.7, respectively).
Discussion : Our study clearly demonstrated that BMI as a simple measure of body composition provides false information concerning true adiposity in physically active male and female students. A similar BMI did not exclude marked differences in the percentage of body fat in sedentary and active students.
... This expanded cohort potentially reflects concordance with studies showing obesity's protective effect against mortality in COPD patients [105,106]. This could also be a result of a healthy worker effect and the imperfect utilization of BMI to define obesity in firefighters with rigorous physical job requirements [107]. In addition, we optimized our model by adjusting for confounding of WTC-OAD cases by using BMI at the time of diagnosis, whereas for subjects that never developed WTC-OAD, BMI at REAP-S was used. ...
Background:
Diet is a modifier of metabolic syndrome which in turn is associated with World Trade Center obstructive airways disease (WTC-OAD). We have designed this study to (1) assess the dietary phenotype (food types, physical activity, and dietary habits) of the Fire Department of New York (FDNY) WTC-Health Program (WTC-HP) cohort and (2) quantify the association of dietary quality and its advanced glycation end product (AGE) content with the development of WTC-OAD.
Methods:
WTC-OAD, defined as developing WTC-Lung Injury (WTC-LI; FEV1 < LLN) and/or airway hyperreactivity (AHR; positive methacholine and/or positive bronchodilator response). Rapid Eating and Activity Assessment for Participants-Short Version (REAP-S) deployed on 3/1/2018 in the WTC-HP annual monitoring assessment. Clinical and REAP-S data of consented subjects was extracted (7/17/2019). Diet quality [low-(15-19), moderate-(20-29), and high-(30-39)] and AGE content per REAP-S questionnaire were assessed for association with WTC-OAD. Regression models adjusted for smoking, hyperglycemia, hypertension, age on 9/11, WTC-exposure, BMI, and job description.
Results:
N = 9508 completed the annual questionnaire, while N = 4015 completed REAP-S and had spirometry. WTC-OAD developed in N = 921, while N = 3094 never developed WTC-OAD. Low- and moderate-dietary quality, eating more (processed meats, fried foods, sugary drinks), fewer (vegetables, whole-grains),and having a diet abundant in AGEs were significantly associated with WTC-OAD. Smoking was not a significant risk factor of WTC-OAD.
Conclusions:
REAP-S was successfully implemented in the FDNY WTC-HP monitoring questionnaire and produced valuable dietary phenotyping. Our observational study has identified low dietary quality and AGE abundant dietary habits as risk factors for pulmonary disease in the context of WTC-exposure. Dietary phenotyping, not only focuses our metabolomic/biomarker profiling but also further informs future dietary interventions that may positively impact particulate matter associated lung disease.
... BMI and waist-to-hip ratio (WHR) are anthropometric indicators representing the body composition accessed at the whole-body level, which focus on the body size, shape, physique, and proportions [16][17][18]. Using BMI and WHR to classify obesity for military personnel as well as individuals in physical-active occupational groups, such as police officers or firefighters, has raised concerns regarding how well it reflects body composition, specifically about distinguishing lean and fat mass, because these populations may have greater muscle mass [19][20][21][22][23]. In a study evaluating active duty US military personnel, for instance, in BF%-defined obese men, 35% and 42% were misclassified as non-obese (false negatives) using BMI and circumference methods, respectively [19]. ...
... In a study evaluating active duty US military personnel, for instance, in BF%-defined obese men, 35% and 42% were misclassified as non-obese (false negatives) using BMI and circumference methods, respectively [19]. Similar higher false-negative rates of BMI-defined obesity has been shown in a US police officer study [20] and US firefighter cohort studies [21,23]. ...
... Table 3 suggested that BMI and WHR criteria was inclined to increase the prevalence of overweight and obesity for military personnel in reference to BFP-based obesity classification (P < 0.01). And previous studies have shown that BMI and WHR methods had high false-negative rates in reference to BFP-defined obesity for US military personnel and firefighters [19,21,23]. So, we examined the false-positive and false-negative rates of BMI-and WHR-determined overweight/obesity in reference to BFP-defined overweight/obesity as shown in Table 3 and Fig. 1. ...
Background:
The rising prevalence of obesity in military personnel has raised great concerns. Previous studies suggest that body mass index (BMI)- and waist-to-hip ratio (WHR)-based obesity classifications in US military personnel and firefighters have high false negative and subsequently cause obesity misclassification.
Objective:
To determine whether BMI and WHR could reflect the fat mass of Chinese military personnel.
Methods:
Three hundred fifty-three male Chinese military personnel and 380 age-matched male adults were recruited. Obesity classification was defined by BMI, WHR, and body fat percentage (BFP).
Results:
Chinese military personnel had extremely low obesity rate determined by either BFP (0.3%) or BMI (0.6%). By combining overweight and obese individuals, BMI- and WHR-determined prevalence of overweight/obesity was 22.4% and 17.0% compared to BFP-based standard (4.0%) (P < 0.05). In reference to BFP, BMI and WHR have high false-positive rate compared to the control group. Further analysis showed that Chinese military personnel consisted of high percentage of BFPlowBMIhigh and/or BFPlowWHRhigh subpopulations. Eighty-one percent of BMIhigh and 78.3% of WHRhigh of them were BFP low.
Conclusions:
Chinese military personnel has extremely low obesity rate. BMI and WHR have high false-positive rates in reference to BFP, which cannot accurately reflect the mass of adipose tissue and leads to obesity misclassification.
... The misclassification of younger adults as well as firefighters as overweight and obese based on BMI has been discussed in several studies. [8][9][10][11][12] These studies utilized bioimpedance testing or skin calipers for body fat percentage (fat mass percentage, FM%) measurement, methods known to have significant levels of error in terms of false positives and false negatives. A series of these studies cite a single article with a sample size of 39 individuals as validation of bioimpedance in comparison to dual-energy x-ray absorption (DXA), but also report DXA as the gold standard for FM% measurement. ...
... A series of these studies cite a single article with a sample size of 39 individuals as validation of bioimpedance in comparison to dual-energy x-ray absorption (DXA), but also report DXA as the gold standard for FM% measurement. [8][9][10]13 This inaccuracy of FM% compared with BMI was addressed thoroughly in one study of US firefighters, demonstrating the potential for false positive and false negative identification of obesity in this population. 10 The importance of misclassification of obesity was demonstrated in a systematic review by Flegal et al, 14 where it was reiterated that all-cause mortality is increased in all grades of obesity in combination relative to normal weight individuals, but that in substratification of obesity classification, grade 1 obesity (BMI 30 to less than 35) demonstrated no elevated mortality and overweight (BMI 25 to less than 30) individuals were associated with a lower all-cause mortality. ...
... [8][9][10]13 This inaccuracy of FM% compared with BMI was addressed thoroughly in one study of US firefighters, demonstrating the potential for false positive and false negative identification of obesity in this population. 10 The importance of misclassification of obesity was demonstrated in a systematic review by Flegal et al, 14 where it was reiterated that all-cause mortality is increased in all grades of obesity in combination relative to normal weight individuals, but that in substratification of obesity classification, grade 1 obesity (BMI 30 to less than 35) demonstrated no elevated mortality and overweight (BMI 25 to less than 30) individuals were associated with a lower all-cause mortality. ...
Objective:
To address which body composition (BC) measures best correlate with cardiorespiratory fitness (CRF) in firefighters and develop a model for accurate CRF estimation compared to traditional methods.
Methods:
Career firefighters had body mass index (BMI) and waist circumference (WC) measured in addition to body fat percentage (FM%) by dual-energy X-ray absorptiometry (DXA). CRF as maximum oxygen uptake (VO2max) was estimated by rowing machine and measured by indirect calorimetry in a treadmill exercise test.
Results:
52 firefighters participated (92.3% male). Univariate correlations with BMI were best with WC. Univariate correlations with VO2max were best with FM%. Obesity classifications by BC measures agreed weakly at best. Multivariate analysis of several variables yielded an improved VO2max estimate (R = 0.70).
Conclusions:
Fire departments may benefit from more sophisticated measures of BC and CRF to evaluate firefighter fitness.
