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Year : 2016  |  Volume : 16  |  Issue : 3  |  Page : 179-184

Occupational physical fitness and eating attitudes of emergency medical services students in Riyadh

Department of Exercise Physiology, College of Sport Sciences and Physical Activity, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication28-Sep-2016

Correspondence Address:
Khaled Salah Kamel
College of Physical Education, Al-Azhar University, Cairo
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-6308.191333

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Aims: To compare occupational, physical fitness and eating attitudes among students at a college for emergency medical services (EMSs) in Riyadh, Saudi Arabia, with American Council on Exercise (ACE) international physical fitness guidelines. Settings and Design: Seventy-three EMS students with a mean age and body mass index of 20.7 ± 1.1 years and 26.3 ± 6.6, respectively, were randomly selected. Participants were asked to complete three suggested ACE physical fitness tests and the Eating Attitudes Test-26 questionnaire. Materials and Methods: We used test protocols and administration to calculate student group percentages and compare results with the ACE guideline test-termination criteria. Statistical Analysis Used: We used a one-sample t-test to assess differences in obtained versus reference scores. Results: Moderate to strong correlations were clearly observed between most variables, especially in the trunk (flexor - extensor) endurance test (r = 0.67, P < 0.01). In addition, a strong correlation between left- and right-sided trunk lateral endurance was observed (r = 0.76, P < 0.01). Regarding ACE guidelines for EMS practitioners, the subjects of this study were not significantly physically fit. Finally, only 16.9% of students exhibited eating disorder risks requiring professional attention. Conclusions: The low level of core physical fitness indicates the need for a special exercise program with a primary focus on EMS responders' abilities to fulfill occupational requirements. A physical exercise intervention program that emphasizes static balance, postural control, and overall flexibility and strength might be important for the prevention of occupational risk among EMS students.

  Abstract in Arabic 

اللياقة البدنية المهنية وعادات الأكل لدى طلاب الخدمات الطبية الطارئة في الرياض
الأهداف: للمقارنة بين اللياقة المهنية واللياقة البدنية و عادات الأكل بين الطلاب في كلية الخدمات الطبية الطارئة (EMSS) في الرياض، المملكة العربية السعودية، مع المجلس الأمريكي للتمارين (ACE) و الدليل العالمي اللياقة البدنية. المواد والطرق: اختير ثلاثة وسبعون طالبا مع متوسط أعمار ومؤشر كتلة الجسم 20.7 ± 1.1 سنوات و 26.3 ± 6.6، على التوالي، تم اختيارهم عشوائيا. وطلب من المشاركين أجراء ثلاثة اختبارات لتمارين مقترحة من اختبارات اللياقة البدنية واختبار من ستة وعشرين سؤالا عن عادات الأكل. استخدمت في هذه الدراسة بروتوكولات الاختبار والإدارة لحساب النسب المئوية لمجموعة من الطلاب ومقارنة النتائج مع مواصفات نهاية الاختبار مع دليل المجلس الأمريكي للتمارين ACE. التحليل الإحصائي المستخدم: استخدمت الدراسة عينة واحدة و اختبارا لتقييم الفروقات التي تم الحصول عليها مقابل معدلات المرجع.النتائج: لوحظ بشكل واضح الارتباط القوي بين معظم المتغيرات، خاصة في الجذع (الانحاء و التمدد) اختبار التحمل (ص = 0.67، P <0.01). بالإضافة إلى ذلك، لوحظ وجود علاقة قوية بين تحمل الجذع الجانبي للجانبين الأيمن و الأيسر (ص = 0.76، P <0.01). وفيما يتعلق بدليل المجلس االأمريكي للياقة البدنية انخفض مستوى اللياقة البدنية لدى عينة الدراسة. وأخيرا،٪ فقط 16.9 من الطلاب أظهروا اضطرابا في الأكل الأمر الذي يتطلب تتطلب اهتماما مهنيا.الاستنتاجات: يشير انخفاض مستوى اللياقة البدنية الأساسية إلى الحاجة إلى ممارسة البرنامج الخاص مع التركيز بشكل أساسي على قدرات المستجيبين EMS "للوفاء بالمتطلبات المهنية. برنامج التمارين البدنية الذي يعزز التوازن الثابت ، والتحكم الوضعي، والمرونة الشاملة والقوة قد تكون مهمة للوقاية من المخاطر المهنية في أوساط طلاب خدمات الطوارئ.

Keywords: Eating Attitudes, emergency medical services, occupational prevention, physical fitness

How to cite this article:
Kamel KS, Aljaloud KS. Occupational physical fitness and eating attitudes of emergency medical services students in Riyadh. Saudi J Sports Med 2016;16:179-84

How to cite this URL:
Kamel KS, Aljaloud KS. Occupational physical fitness and eating attitudes of emergency medical services students in Riyadh. Saudi J Sports Med [serial online] 2016 [cited 2022 Oct 6];16:179-84. Available from: https://www.sjosm.org/text.asp?2016/16/3/179/191333

  Introduction Top

Emergency medical technicians (EMTs) transport patients to medical facilities and provide quick responses and care for injured and sick people in emergency medical situations. EMTs perform several tasks that result in localized strain of the back. [1],[2] A lack of physical fitness and overweight/obesity are associated with an increased incidence of injuries and chronic diseases among intervening EMTs. The National Association of EMTs (NAEMTs) states that EMTs are seven times more likely to miss work than the average worker because of injury; in addition, half of EMTs are reported to suffer from back pain, and a quarter will suffer a career-ending injury within the first 4 years of service. [3] Furthermore, EMTs have a higher frequency of injuries and sicknesses relative to the USA national average. [4]

According to the NAEMT, overweight patients are directly related to an increase in injury statuses among emergency medical services (EMSs) practitioners as lifting and maneuvering overweight patients places extra stress on EMTs, resulting in an increased risk of lower back injury. Back injuries are common among EMTs, [5] and many investigations of work-related injuries in this population have confirmed the risks and concerns related to a lack of physical fitness and occupational injuries. [1],[6],[7],[8],[9] The USA Bureau of Labor Statistics reported that 84% of injuries involved torsion and stress, mainly in the hands and fingers, and 42% affected the lower back; these latter complicated injuries resulted from moving or lifting injured persons. [10] These high rates of injuries among EMTs support the importance of increased job-related physical fitness among EMS practitioners. In other words, EMTs should be physically fit in order to accomplish their work flawlessly and securely. [11]

The American Council on Exercise (ACE), in collaboration with the NAEMTs, developed suggested physical fitness guidelines for EMTs. [3] These guidelines were developed according to a group of exercise physiologists from different states of the USA, who witnessed EMTs in the field. The physiologists conducted a task analysis based on gathered information, which served as the groundwork for the physical fitness testing recommendations in the study. These procedures were intended to reduce the severity of musculoskeletal injuries incurred by EMTs while on the job. In addition, the ACE physical fitness guidelines are used to screen EMTs and thus differentiate those at an increased risk of movement-related injuries from those with a lower risk.

The Eating Attitudes Test (EAT-26) is the most widely used homogenous self-report test for the determination and distinction of symptoms related to eating disorders. [12] EAT-26 can be used in individual or group settings and is intended to be used by psychological specialists, coaches, college therapists, and others with an interest in collecting information in order to determine whether an individual should be referred to a professional for eating disorder consultation. This test is intended primarily for the evaluation of adolescents and adults. A skilled expert may decide whether an individual with a score 20 or higher on the test meets the diagnostic criteria for an eating disorder.

As the Kingdom of Saudi Arabia experiences increasing development and population growth coupled with industrial and commercial expansion, EMSs have a justifiable need to minimize the effects of accidental mishaps and injuries. The mission of EMS-focused colleges is to seek excellent medical contributions through the achievement of quality as a basis for achieving excellence in line with international criteria. This study intended to compare the occupational, physical fitness of EMS students relative to the ACE international physical fitness guidelines and to determine if this group of students exhibited eating disorder risks requiring professional attention.

  Materials and methods Top


Seventy-three male students from a college focused on EMS in Riyadh, Saudi Arabia, were randomly selected to participate in this study as a part of a physical fitness course supervised by the university Exercise Physiology Department. All students provided written informed consent in which they stated that they were healthy, agreed to participate in the study, and reported any conditions such as diabetes, cardiovascular disease, back surgery, or other medical situations that could prevent them from safely performing exercises; [13] ultimately, none of the students were excluded because of these conditions. Students answered the EAT-26 questionnaire, which was distributed to assess the eating disorder risk. [14] Only 65 students completed this questionnaire; their responses were used to calculate the risks of bulimia, dieting, food anxiety, and oral control.


Three types of assessment were selected from the ACE for the NAEMT. [3] First, stability tests included (1) the Stork-Stand Balance Test to assess static balance during a timed standing exercise on one foot; students' performances were categorized as poor, fair, average, good, or excellent if they balanced for <20 s, 20-30 s, 31-40 s, 41-50 s, or >50 s, respectively. In addition, (2) the Sharpened Romberg Test was used to assess stationary balance and postural control during a timed standing exercise on a reduced base of support in the absence of visual sensory input; good postural control was defined as >30 s, whereas poor postural control was defined as <30 s. [15],[16],[17]

Second, the core function test comprised McGill's Torso Muscular Endurance Test Battery. [18] This battery includes complex movements with repeated alterations to evaluate the three-dimensional torque needed to support various trunk positions. The battery consists of the following: (1) the trunk flexor endurance test (flexor), which is used to assess the endurance of core muscles; this timed test involves a static, isometric contraction of the anterior muscles to stabilize the spine until the individual exhibits fatigue and can no longer hold the assumed position. (2) The trunk lateral endurance test (lateral) measures the endurance of the lateral core muscles on each side of the trunk, which stabilizes the spine. (3) The trunk extensor endurance test (extensor) measures the muscular endurance of the trunk extensor muscles; this timed test involves an isometric contraction of the trunk extensor muscles that stabilize the spine. Clearly, the individual test results in this testing battery were not a primary indicator of current or future back problems; McGill has proven that relationships among the tests are significant signs of muscle imbalances that can cause back pain. McGill suggests that the flexion/extension ratio should be <1.0. The right-side bridge: left-side bridge scores should not exceed 0.05 from a balanced score of 1.0. The side bridge (either side): extension ratio should be <0.75. These ratios indicate balanced endurance among the muscle groups.

Third, stability and mobility tests included the following: (1) a modified body weight squat test to assess muscular fitness of the lower back when performing repeated squat-to-stand movements at knee flexion angles of 45-90°, (2) a front plank (FP) to assess the ability of the core musculature to hold the spine in alignment while the body is in a forearm plank position, and (3) an overhead reach to assess the flexibility of shoulder joints in exterior rotation. All ACE tests protocols, administrations, and general interpretations were considered during the measurement and data collection stages.

Statistical analyses

Data were statistically analyzed using the IBM SPSS Statistics 22.0 software program (SPSS, Inc., Chicago, IL, USA). The results are presented as means with standard deviations (SDs) and ratios. A one-sample t-test was used to compare the mean of each fitness test versus the ACE international criteria. A Pearson's correlation was used to investigate the correlations of fitness test results with weight, waist, and body mass index (BMI) measurements and thus identify the relationship between body composition and fitness level in the EMS participants. In addition, the percentage of EMS participants who achieved acceptable scores according to the ACE fitness test criteria was calculated. Finally, the mean EAT-26 total score (with SD), the percentage of positive scores, and scores for bulimia, dieting, food anxiety, and oral control were also calculated.

  Results Top

The mean (±SD) age, weight, height, waist, and BMI of the 73 subjects are shown in [Table 1].
Table 1: Subject characteristics (n=73)

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The ACE physical fitness test results for EMS students, including those of stability tests, core function tests, and stability and mobility tests are illustrated in [Table 2]. The means (+SDs) were compared with the ACE criteria for adult men. The results include the reference or cutoff scores and percentages of participants who achieved or exceeded the average score for each ACE physical fitness test.
Table 2: American Council on Exercise physical fitness tests (n=73)

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A one-sample t-test was used to assess the differences between the obtained scores and reference scores developed by the ACE. The results are summarized in [Table 3]. The results clearly demonstrate that subjects of this study were not significantly physically fit in terms of the ACE guidelines for EMS practitioners, particularly with regard to physical fitness measured using the McGill's Torso Muscular Endurance Test Battery.
Table 3: T‑test for the stability, core function, and stability and mobility tests compared to the American
Council on Exercise criteria for adults male (n=73)

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Correlations between variables are presented in [Table 4]. The results clearly revealed moderate to strong correlations between most of the variables, especially the trunk flexor and trunk extensor endurance tests (r = 0.67, P < 0.01). In addition, a strong correlation was observed between the trunk lateral endurance (left-side) and trunk lateral endurance (right side) tests (r = 0.76, P < 0.01). Furthermore, the body composition data correlated negatively with trunk lateral endurance tests (both left and right sides), as well as the FP test (r = −0.232 to −0.424, P < 0.01-0.05).
Table 4: Pearson's correlation analysis of stability, core function, and stability and mobility tests relative to American
Council on Exercise criteria for adult men

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81.1% of the students had a negative EAT 26 score (<20); 16.9% had a positive EAT 26 score (> 20) as presented in [Table 5].
Table 5: Mean (±SD) EAT-26 total score, percentage of EAT-26 positive scores, and dieting, bulimia and food
preoccupation, and oral control factors in EMS students

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  Discussion Top

The primary purpose of the present study was to compare the physical fitness level of a group of EMS students in Saudi Arabia with the international physical fitness guidelines developed by the ACE. The results demonstrated that the students had characteristics similar to those of the average adult male EMTs used as a reference group for the ACE guidelines, except for a slight elevation in BMI (26.3 ± 6.6). However, the mean waist circumference was normal (83 ± 25 cm), indicating a lack of abdominal fat accumulation. Fat accumulation has been strongly and directly associated with waist circumference. [19]

[Table 2] compared the mean (±SD) scores of stability tests, core function tests, and mobility tests with the ACE criteria for adult men and reported the percentages of participating students who achieved or exceeded the average score for each ACE physical fitness test. The students did not meet the minimum McGill's torso muscular endurance test recommendation with respect to trunk muscular endurance. The statistics indicated that the mean trunk extensor endurance score was lower than the mean trunk flexor and lateral trunk endurance scores (right- and left- sides). Moreover, the following percentages of participants achieved average (acceptable) scores on McGill's tests: 19.2% for the extension/flexion ratio, 27.4% for the right/left ratio, 31.5% for the right trunk/extension, and 42.4% for the left trunk/extension. Therefore, a number of students may be at risk of experiencing a lower back injury because of poor trunk extensor endurance. This result is supported by a statement from the US Bureau of Labor Statistics, in which EMS professionals were listed as having a higher than average potential for injuries related to physical job responsibilities, especially musculoskeletal injury when compared with professionals in other occupations. [4] A one-sample t-test used to assess differences between the obtained and reference scores clearly revealed a lack of significant physical fitness among the subjects of this study, particularly in terms of physical fitness related to the McGill's Torso Muscular Endurance Test Battery.

Some investigators studied the obesity epidemic and future emergency responders and found that excess weight is highly prevalent and associated with lower exercise tolerance among future emergency responders. [11] Other studies concluded that carrying equipment and patients over long distances, which constitutes part of the daily occupational tasks of EMS workers, may lead to injuries, including back injuries, and thus may impede sufficient work performance; this factor has been identified as a problem within the profession. [8],[20] Consequently, any increase in body weight may elevate the risk of occupational injuries, especially lower back injuries.

Moreover, the statistical results indicated a strong correlation between trunk flexor endurance and trunk extensor endurance (r = 0.67, P < 0.01). In addition, a strong correlation was observed between the trunk lateral endurance (left-side) and trunk lateral endurance (right side) tests (r = 0.76, P < 0.01). Furthermore, the body composition data correlated negatively with the results of trunk lateral endurance tests (left and right sides) and the FP test (r = −0.232 to = 0.424, P < 0.01−0.05). However, existing evidence suggests that the ability of the trunk muscles to maintain appropriate activation levels over long periods might be more important than maximum strength in terms of protecting the passive structures of the lumbar spine from injury. [21],[22] It has also been suggested that sufficient trunk muscle endurance contributes to spinal stability during strenuous and prolonged physical tasks. [23] The amount of muscle activation needed to achieve sufficient stability is a moving target that changes continually as a function of the three-dimensional torque needed to support postures. In addition, anticipatory stiffness is needed to endure unexpected loads, to prepare to move quickly, or to ensure sufficient stiffness in any degree of joint freedom, which may be compromised from injury. Motor control fitness is essential to achieving the targeted stability under all possible conditions to ensure performance and injury avoidance. [22] Only 16.9% of the students in this study had eating disorder risks requiring professional attention, according to the EAT-26. All participants in the present study were young and had not yet begun to work in the field. Thus, EMS training programs should consider the importance of physical fitness development and improvement assessments to ensure their students' qualification for occupational jobs in the future.

  Conclusion Top

When preparing EMS graduates for their future occupation, evidence is needed to determine that those graduate students are physically healthy and able to perform their jobs successfully without being at risk. The results of the present study highlight the insufficient physical fitness among EMS students at the participating institution. The low level of core physical fitness among students in this study is alarming because it indicates that the students are at risk of injury after graduation and during their future professional careers. For the purpose of prevention, all participants may need to improve their physical fitness level, especially with regard to musculoskeletal trunk endurance. Education and physical exercise intervention programs that emphasize static balance, postural control, and overall flexibility and strength may be important for the prevention of occupational risks among future EMS students. A controlled investigation of such a prevention program would be a very appropriate next step.


Authors thank Prince Sultan bin Abdulaziz EMS College for their assistance in facilitating this study.

Financial support and sponsorship

A grant from the research center for the sport science and physical activity college, Deanship of Scientific Research at King Saud University.

Conflicts of interest

There are no conflicts of interest.

  References Top

Jones AY, Lee RY. Cardiopulmonary resuscitation and back injury in ambulance officers. Int Arch Occup Environ Health 2005;78:332-6.  Back to cited text no. 1
Lavender SA, Conrad KM, Reichelt PA, Johnson PW, Meyer FT. Biomechanical analyses of paramedics simulating frequently performed strenuous work tasks. Appl Ergon 2000;31:167-77.  Back to cited text no. 2
National Association of Emergency Medical Technicians; 2016. Available from: . [Last accessed on 2016 Mar 25].  Back to cited text no. 3
Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, 2016-17 Edition, EMTs and Paramedics; 2016. Available from: . [Last accessed on 2016 Mar 25].  Back to cited text no. 4
Studnek JR, Crawford JM. Factors associated with back problems among emergency medical technicians. Am J Ind Med 2007;50:464-9.  Back to cited text no. 5
Crill MT, Hostler D. Back strength and flexibility of EMS providers in practicing prehospital providers. J Occup Rehabil 2005;15:105-11.  Back to cited text no. 6
Gershon RR, Vlahov D, Kelen G, Conrad B, Murphy L. Review of accidents/injuries among emergency medical services workers in Baltimore, Maryland. Prehosp Disaster Med 1995;10:14-8.  Back to cited text no. 7
Hogya PT, Ellis L. Evaluation of the injury profile of personnel in a busy urban EMS system. Am J Emerg Med 1990;8:308-11.  Back to cited text no. 8
Schwartz RJ, Benson L, Jacobs LM. The prevalence of occupational injuries in EMTs in New England. Prehosp Disaster Med 1993;8:45-50.  Back to cited text no. 9
Reichard AA, Marsh SM, Moore PH. Fatal and nonfatal injuries among emergency medical technicians and paramedics. Prehosp Emerg Care 2011;15:511-7.  Back to cited text no. 10
Tsismenakis AJ, Christophi CA, Burress JW, Kinney AM, Kim M, Kales SN. The obesity epidemic and future emergency responders. Obesity (Silver Spring) 2009;17:1648-50.  Back to cited text no. 11
Garner DM, Garfinkel PE. The Eating Attitudes Test: An index of the symptoms of anorexia nervosa. Psychol Med 1979;9:273-9.  Back to cited text no. 12
Evans K, Refshauge KM, Adams R. Trunk muscle endurance tests: Reliability, and gender differences in athletes. J Sci Med Sport 2007;10:447-55.  Back to cited text no. 13
Garner DM, Rosen LW, Barry D. Eating disorders among athletes. Research and recommendations. Child Adolesc Psychiatr Clin N Am 1998;7:839-57.  Back to cited text no. 14
Black FO, Wall C rd, Rockette HE Jr., Kitch R. Normal subject postural sway during the Romberg test. Am J Otolaryngol 1982;3:309-18.  Back to cited text no. 15
Hastad DN, Lacy AC. Measurement and Evaluation in Contemporary Physical Education. Upper Saddle River, New Jersey: Gorsuch Scarisbrick Publishers; 1989.  Back to cited text no. 16
Newton R. Review of tests of standing balance abilities. Brain Inj 1989;3:335-43.  Back to cited text no. 17
McGill S. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Champaign, IL: Human Kinetics; 2007.  Back to cited text no. 18
Després JP. Health consequences of visceral obesity. Ann Med 2001;33:534-41.  Back to cited text no. 19
Stilwell JA, Stilwell PJ. Sickness absence in an ambulance service. J Soc Occup Med 1984;34:96-9.  Back to cited text no. 20
Biering-Sørensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine (Phila Pa 1976) 1984;9:106-19.  Back to cited text no. 21
McGill SM, Grenier S, Kavcic N, Cholewicki J. Coordination of muscle activity to assure stability of the lumbar spine. J Electromyogr Kinesiol 2003;13:353-9.  Back to cited text no. 22
Koumantakis GA, Watson PJ, Oldham JA. Supplementation of general endurance exercise with stabilisation training versus general exercise only. Physiological and functional outcomes of a randomised controlled trial of patients with recurrent low back pain. Clin Biomech (Bristol, Avon) 2005;20:474-82.  Back to cited text no. 23


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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