Characterizing the Quality of On- and Off-Shift Dietary Intake by EMS Personnel and Firefighters in Southern New Hampshire
Emergency medical service (EMS) workers face emotionally and physically demanding situations daily, especially first responders. Sudden cardiac events are the leading cause of on-duty death among firefighters, accounting for about 45 percent (1), and it is thought that personal cardiovascular disease (CDV) risk factors and the stress of occupational demands are contributing elements (2). Given the high rates of obesity, cardiovascular disease, and mental health risks in first responders, there is a need for policy-level changes that address structural barriers to health. By prioritizing preventive health strategies for first responders, we can protect the communities they serve, ensuring that emergency personnel remain physically and mentally fit to perform their duties at full capacity.
Some research has been done regarding the health risks associated with career EMS workers. Fatigue, a common physiological sign in firefighters and EMS workers, has been found to interfere with meal cooking and planning, while sleep loss may lead to taking in more calories than necessary to maintain optimal health (3). One systematic review has compared the eating patterns of fatigued night-shift workers with those of day-shift workers (4). Some studies have considered the day versus night macronutrients of people doing shift work, with night shifts often characterized by greater energy intake and decreased physical activity (5,6).
However, studies examining the dietary intake of EMS personnel are limited. One of the many challenges these individuals face is the inconsistency in their mealtimes and the requirement for fast, low-effort foods, which can negatively impact physical health in the long term. Understanding this target population’s dietary and nutritional habits is important for developing future health promotion programs aimed at improving dietary habits and reducing CVD risk in EMS personnel.
As a volunteer EMT as well as a biomedical science and nutritional sciences double major, I have personal goals of attending medical school and serving my community and its members, as well as optimizing my personal health through nutrition, exercise, and overall healthy habits. I’ve noticed clear differences in my habits and food intake when I am on-shift at the EMS station in comparison with an average day of eating, movement, screen time, and sleep. When I first began brainstorming for my Honors senior thesis, I knew I wanted to investigate this difference and whether other EMS workers or first responders noticed the same changes in their own habits. I applied for an Undergraduate Research Award and was fortunate enough to receive funding to complete this project.
After conducting a literature review to see what projects were completed on similar topics, I noticed an evident gap in research on the health of this population. Existing research compared the eating habits of night-shift workers with day-shift workers and focused more on exercise interventions for this population than on nutrition. I set out to make my project different by comparing EMS workers’ nutritional intake while working long shifts with their regular intake when not at work. This study examined dietary habits including sodium, saturated fat, and added sugar intake with the hypothesis that these three nutrients are consumed in greater portions while on-shift because of the necessity for quick food and the tendency for fast food to be higher in these three components (7). Data from this study could lead to more interest in the nutritional intake of first responders, which may in turn encourage EMS stations to help support their workers in making healthier decisions and eating less processed foods while on-shift.
Experiment
This study was designed as a cross-sectional study that used a dietary assessment tool along with surveys to collect data from January 22 to March 13, 2025. Before beginning the recruitment process, I obtained approval from the UNH Institutional Review Board (IRB) for this research study (IRB-FY2025-93). Study participants were EMS workers and firefighters from stations in Durham and Dover, New Hampshire. Participants were recruited through various methods, including flyers, messages sent through station newsletters or messaging platforms, and brief presentations.
In this community nutrition study, it was more challenging than expected to generate interest and for participants to fulfill the study requirements. First responders face incredibly varied schedules and unpredictable calls that may have hindered their ability to complete the study requirements. The final sample included nine participants (six females and three males), which was a lower participation rate than anticipated.
I collected dietary intake data for 24-hour recalls using the Automated Self-Administered 24-hour (ASA24) Dietary Assessment Tool, version (2024), developed by the National Cancer Institute in Bethesda, Maryland. A 24-hour recall is a widely accepted nutritional intake method in which the individual is prompted to share every drink and food item they consumed in the previous 24 hours. The tool records specific dietary data that includes macronutrient, mineral, added sugar, vitamin intake, and more. This is an efficient program that allows the researcher to connect with a higher number of participants with less overall effort and resources needed (8). The ASA24 platform includes some standardized, common meals such as a ham sandwich or popular granola bars, but the majority of meals that participants consume require them to input different meal components with specificity for the amount (i.e., half a teaspoon, one cup, etc.), the quality (i.e., low-calorie, low-sodium, etc.), and the frequency or number of servings consumed (i.e., two cookies, half a sandwich, etc.).
Before the first ASA24 recall, all participants received an email with instructions on how to complete the dietary recalls. I monitored each participant’s progress and recorded the completion of various study components in the code book. Participants completed a total of three recalls: two days for on-shift and one day for off-shift. I collected a total of twenty-seven recalls through the ASA24 platform.
A survey was also sent out via the TextMagic platform to gather participants’ demographic data, which was used to determine their Dietary Reference Intake (DRI) requirements based on USDA guidelines (9). I also determined body mass index (BMI) using the demographic survey data. Participants completed the demographic questionnaire in Qualtrics and then provided their contact information and preferred method for receiving their thirty-dollar e-gift card. All gift cards were distributed via the Tango (Tangocard.com) platform. The total required time for each participant to complete all three recalls and the survey was estimated to be one and a half to two hours. After completing the study, participants received a standardized debrief email that included dietary recommendations, guidelines, and healthcare worker–tailored healthy eating tips. All email communication was sent through the research lab’s UNH email account.
Once I finished collecting data on dietary intake, it was time to organize and look for the relevant information related to my hypothesis that sodium, saturated fat, and added sugar would be eaten in increased portions while on-shift. After data cleaning, which entailed separating probable results from outliers that would skew the data, I exported the ASA24 data into CSV/Excel files that could be imported into the SAS statistical software program for data analysis. This program was then used to turn this data into relational graphs and charts as well as calculate averages, totals, and any other necessary information required to see the dietary quality of the participants’ meals. The main outcomes for this study were total intakes of sodium, saturated fat, added sugars, whole grains, fiber, and dietary quality measured via the Healthy Eating Index (HEI-2015). HEI-2015 data was synthesized through SAS using specific codes for importing ASA24 data into SAS. I conducted descriptive statistics (means, standard deviations, frequencies, and proportions) for all outcome variables.
Results
To formulate results, I compared each dietary component with the Dietary Guidelines for Americans 2020–2025 (10), which sets guidelines and recommendations for intake of food components and calories, as well as for exercise. The Dietary Guidelines include specific recommendations for three nutrients because of implicated health risks from their overconsumption: Saturated fat and added sugar should constitute less than 10 percent of daily calories, while sodium consumption should be limited to 2,300 mg/day or less (10).
Figure 1: Total percent calories from saturated fat and added sugars and total sodium intake (mg).
The study participants’ average overall fat, saturated fat, and sodium intake exceeded national recommendations both on- and off-shift (Figure 1), while added sugars were within the recommendations. Excessive intakes of saturated fat and sodium are two main characteristics of atherogenic dietary patterns. Atherogenic dietary patterns are those associated with increased cardiovascular risk and generally consist of high saturated fat and sodium intake, low fruit and vegetable intake, and low intake of milk and dairy foods (11). The dietary patterns seen in this study match those of an atherogenic diet, which can show an increased risk of cardiovascular disease.
Another component we considered was total grains, which can be divided into two categories: whole and refined. Whole grains have health benefits, providing more fiber, vitamins, minerals, and other nutrients while lowering cholesterol levels and blood pressure (12). According to the Dietary Guidelines for Americans 2020–2025, whole grains should account for at least half of the grains consumed (13). Within this study sample, whole grains were under-consumed both on- and off-shift (Figure 2). This is another characteristic of an atherogenic diet (11).
Figure 2: Percentage of total grains, either whole or refined, for overall, on-shift, and off-shift.
Fiber, another component that was analyzed in this study, is an essential component of a healthy diet because it lowers the risk of diabetes, heart disease, and various types of cancer (14). According to the Dietary Guidelines for Americans 2020–2025, females aged 19 to 50 should consume between 25 and 28 grams of fiber daily, while males in the same age range should consume 31 to 34 grams of fiber each day (10). Both male and female study participants consumed less than the recommended amounts of dietary fiber, which is again indicative of an atherogenic diet.
Figure 3: Representation of participant total HEI scores.
In general, HEI diet quality scores for participants were above the national average (Figure 3). The HEI-2015 component score for added sugars suggests greater adherence to dietary guidelines, meaning the participants consumed on average a reasonable amount of sugar. However, excessive intakes of saturated fat and sodium persist. In addition, HEI-2015 component scores suggest low adherence to recommended intakes for total fruit, whole fruit, and whole grains.? High saturated fat and sodium intake are both components that are associated with CVD risk (15,16). The lower intake of added sugars from this data indicates lower CVD risk because of added sugar intake (17).
The data obtained in this study through qualitative and quantitative means highlights some critical points of intervention that may apply to other firefighters and EMS workers with similar baseline dietary intakes. Possible dietary intervention points include saturated fat, sodium, whole grains, whole fruit, and vegetable intake.? As shown from the qualitative survey results, most participants reported that the days they completed ASA24 recalls were relatively accurate representations of a typical day for them, whether on- or off-shift. This is important information, as with only three recalls, a day considered abnormal could skew the participant’s overall data.
Personal Reflection and Conclusion
From this experience I gained a new appreciation for the difficulties involved with community-based research. Because ASA24 is an online platform, it’s possible that individuals felt less motivated to complete their recalls without human interaction to encourage them. Future studies should consider this when selecting a dietary intake method for data collection. Another challenge was the highly unreliable call volume in this line of work, which could potentially affect the dietary habits of EMS workers and firefighters and skew the numbers. This study also included EMS workers and firefighters from two different stations, which may contribute to variability because of the distinct roles of each occupational position and the differing practices at each station, as well as differences in meal habits between groups. Something I had not considered before data collection was the rank and roles of participants, which is a variable that could potentially affect the time and availability of nutritious food options. Future research could examine various contextual factors, such as rank, gender, and type of organization, that may influence dietary habits while on-shift. A larger study with a more diverse demographic, such as one covering the entire state of New Hampshire, also would be beneficial in understanding the broader context of EMS and firefighter dietary patterns and habits.
Overall, the findings of my exploratory research study encourage increased awareness of the health of this population and the need to understand better the health risks related to firefighter and EMS diets. High fat, saturated fat, and sodium intake, and low intake of whole grains, are all indicative of an atherogenic diet (11), which could contribute to the increased heart disease prevalence in firefighter and EMS worker populations. Future research directions should include the effectiveness of workplace nutrition and wellness interventions in high-stress, high-risk professions; what works, what doesn’t; and how interventions can be tailored for maximum adherence. My hope is that the information obtained from this study and from related future research will guide changes for EMS stations to better support their workers by making it easier for them to choose healthier foods, thereby helping them meet nutritional guidelines. Possible changes might include providing their workers with healthy eating options, such as quick snacks; running healthy lifestyle programs such as encouraging exercise and better nutrition at EMS and fire stations; and promoting more station meals instead of requiring each individual to find or prepare their own meals every shift.
It was an incredible opportunity to work alongside members of UNH’s Maternal and Early Childhood Nutrition and Health Equity Research Lab and Dr. Mena herself, and to learn from the EMS workers and firefighters who participated, as well as from my colleagues. Thank you to Mr. Dana Hamel and the Hamel Center for Undergraduate Research for providing me with this opportunity.
References
1. Ras J, Kengne AP, Smith DL, Soteriades ES, Leach L. Association between cardiovascular disease risk factors and cardiorespiratory fitness in firefighters: A systematic review and meta-analysis. Int J Environ Res Public Health. 2023;20(4):2816. doi:10.3390/ijerph20042816
2. Drew-Nord DC, Hong O, Froelicher ES. Cardiovascular risk factors among career firefighters. AAOHN J Off J Am Assoc Occup Health Nurses. 2009;57(10):415–422, quiz 423. doi:10.3928/08910162-20090928-04
3. Mansouri T, Ghanatios G, Hatzinger L, et al. Eating patterns among emergency medical service providers in the United States: A qualitative interview study. Nutrients. 2022;14(22):4884. doi:10.3390/nu14224884
4. Bonham MP, Bonnell EK, Huggins CE. Energy intake of shift workers compared to fixed day workers: A systematic review and meta-analysis. Chronobiol Int. 2016;33(8):1086–1100. doi:10.1080/07420528.2016.1192188
5. Bouillon-Minois JB, Thivel D, Croizier C, et al. The negative impact of night shifts on diet in emergency healthcare workers. Nutrients. 2022;14(4):829. doi:10.3390/nu14040829
6. Mansouri T, Hostler D, Temple JL, Clemency BM. Eating and physical activity patterns in day and night shift EMS clinicians. Prehosp Emerg Care. 2022;26(5):700–707. doi:10.1080/10903127.2021.1996662
7. Kirkpatrick SI, Reedy J, Kahle LL, Harris JL, Ohri-Vachaspati P, Krebs-Smith SM. Fast-food menu offerings vary in dietary quality, but are consistently poor. Public Health Nutr. 2014;17(4):924–931. doi:10.1017/S1368980012005563
8. Kirkpatrick SI, Subar AF, Douglass D, et al. Performance of the Automated Self-Administered 24-hour Recall relative to a measure of true intakes and to an interviewer-administered 24-h recall. Am J Clin Nutr. 2014;100(1):233–240. doi:10.3945/ajcn.114.083238
9. DRI Calculator for Healthcare Professionals | National Agricultural Library. Accessed February 11, 2025. https://www.nal.usda.gov/human-nutrition-and-food-safety/dri-calculator
10. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov.
11. MindTap—Cengage Learning. Accessed May 11, 2025. https://ng.cengage.com/static/nb/ui/evo/index.html?deploymentId=5000181…;
12. The whole truth about whole grains. Mayo Clinic. Accessed April 30, 2025. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eati…
13. MyPlate.gov | Grains Group—One of the Five Food Groups. Accessed April 30, 2025. https://www.myplate.gov/eat-healthy/grains
14. How to add more fiber to your diet. Mayo Clinic. Accessed April 30, 2025. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eati…
15. Guasch-Ferré M, Babio N, Martínez-González MA, et al. Dietary fat intake and risk of cardiovascular disease and all-cause mortality in a population at high risk of cardiovascular disease. Am J Clin Nutr. 2015;102(6):1563–1573. doi:10.3945/ajcn.115.116046
16. Wang YJ, Yeh TL, Shih MC, Tu YK, Chien KL. Dietary sodium intake and risk of cardiovascular disease: A systematic review and dose-response meta-analysis. Nutrients. 2020;12(10):2934. doi:10.3390/nu12102934
17. Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R, Hu FB. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med. 2014;174(4):516–524. doi:10.1001/jamainternmed.2013.13563
Author and Mentor Bios
Ellianna Jordan, B.S., is a recent University of New Hampshire 2025 alumna from Brookline, New Hampshire, who graduated with a double major in biomedical science and nutritional sciences. Ellianna was a volunteer EMT at McGregor Memorial EMS while a student at UNH, as well as a member of the Mena Research Lab, and is continuing to pursue a career in medicine by applying to medical school.
Noereem Z. Mena, RDN, LD, is a bilingual (English/Spanish) registered dietitian nutritionist and assistant professor of nutrition in the Department of Agriculture, Nutrition, and Food Systems at the University of New Hampshire. Dr. Mena’s research efforts are focused on promoting healthy eating behaviors in early childhood.
Copyright 2026 ? Ellianna Jordan
