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Importance: US firefighters are a working population at risk of chronic diseases, including obesity, cardiovascular disease, and cancer. This risk may be mitigated by a healthy diet., Objective: To evaluate the effect of a Mediterranean nutrition intervention using a behavioral/environmental approach (firefighter/fire station/home) at the individual participant level., Design, Setting, and Participants: This 12-month cluster randomized clinical trial included US career firefighters from fire stations and homes within 2 Indiana fire departments. Participants were randomized by fire station to either Mediterranean diet or control (usual care). The study was conducted from October 2016 to December 2019, and data were analyzed in November 2022., Intervention: For the first 12 months of the study, firefighters located at fire stations randomized to the intervention group were provided with access to supermarket discounts and free samples of Mediterranean diet foods, online nutrition education platforms, email announcements and reminders, family and peer education and support, and chef demonstrations. Firefighters in fire stations allocated to the control group received no intervention and were instructed to follow their usual diet., Main Outcomes and Measures: Change in dietary habits at 12 months as measured by a modified Mediterranean diet score (range, 0 to 51 points) at baseline and 6-month and 12-month follow-up. Cardiometabolic parameters were secondary outcomes., Results: Of 485 included firefighters, 458 (94.4%) were male, and the mean (SD) age was 47 (7.5) years. A total of 241 firefighters (27 fire stations) were randomized to the Mediterranean nutrition intervention, and 244 (25 fire stations) were randomized to usual diet. Outcomes were analyzed using generalized linear mixed models for modified Mediterranean diet score at 6 months (n = 336) and 12 months (n = 260), adjusting for baseline age, sex, race and ethnicity, fire department, physical activity, and waist circumference. In the intervention group compared with the control group, the modified Mediterranean diet score significantly increased by 2.01 points (95% CI, 0.62-3.40; P = .005) at 6 months and by 2.67 points (95% CI, 1.14-4.20; P = .001) at 12 months. Among secondary outcomes, changes in cardiometabolic risk factors were not statistically significant at 1 year. Results from analyses with multilevel multiple imputation for missingness were similar., Conclusions and Relevance: In this Mediterranean nutrition intervention of multicomponent behavioral/environmental changes, career firefighters had increased adherence to a Mediterranean diet., Trial Registration: ClinicalTrials.gov Identifier: NCT02941757.

Among US firefighters, cardiovascular disease is the leading cause of on-duty death. Poor diet contributes to this burden, but effective strategies to encourage healthy eating in the fire service are not established. "Feeding America's Bravest" motivates firefighters and their families to modify their food culture and reduce cardiometabolic risk profiles by adopting Mediterranean diet principles. Feeding America's Bravest is a cluster-randomized, controlled trial within the 44 stations of the Indianapolis Fire Department, including about 1000 firefighters. It compares a Mediterranean Diet Nutritional Intervention (MDNI) (group 1) vs. usual care (group 2) for 12months; followed by 12months of self-sustained continuation phase in the group 1 and cross-over to Mediterranean Diet Nutritional Intervention in group 2. Group 2 will receive the MDNI for 6months to test the efficacy of a shorter intervention followed by 6months of self-sustained phase. The intervention includes behavioral and environmental components. The primary outcome is 12-month change in Mediterranean diet score comparing group 1 vs. group 2; we will also assess 12- and 24-month change in group 1, and 6- and 12-month change in group 2, from baseline. Secondary outcomes are changes in body weight, body composition and other cardiometabolic risk markers; and correlations between self-reported dietary habits and biomarkers of dietary adherence. This innovative trial tests a novel worksite approach to introduce Mediterranean diet among US firefighters, through multi-pronged MDNI combining evidence-based behavior change strategies with economic incentives, family and peer support and environmental changes, informing recommendations for the US fire service and potentially other similar workforces., Trial Registration Number: NCT02941757., (Copyright © 2017 Elsevier Inc. All rights reserved.)