A Hot Topic

When taking prospective members on a tour of a fitness facility, salespeople frequently will highlight the availability of whirlpools, steam rooms, and sauna baths. Typically, this has been an effective marketing tool because most people have experienced the pleasant sensation of heat from one of these three amenities that has left them temporarily feeling relaxed and free of physical pain and emotional stress. However, these heated venues also present numerous health concerns that in turn pose serious liability issues to the management of any facility. Often the manufacturers and purveyors of whirlpools, steam rooms, and sauna baths will tout the alleged benefits of this kind of exposure to heat. Frequently heard is the claim that sweating will help rid the body of dangerous toxins and, therefore, many persons believe that these venues offer real health benefits. In reality, sweat only contains trace amounts of toxins and, therefore, these amenities provide no real health benefits other than temporary relaxation and, perhaps, the ability to relieve temporarily congestion of breathing passages and sinuses. Dee A. Glaser, M.D., vice chairman and professor of the Department of Dermatology at St. Louis University and a founding member of the International Hyperhidrosis Society, a medical group dedicated to the study and treatment of heavy sweating, has commented frequently on the many misconceptions associated with sweating. She has stated, “In the big picture, sweat has only one function: cooling you down when you overheat. Sweating for the sake of sweating has no other benefits, and sweating heavily is not going to release a lot of toxins (12).” Specifically, it is the liver and the kidneys, not the sweat glands, which are the organs responsible for filtering toxins from the blood. In fact, if one does not compensate for sweating heavily by drinking enough fluid, dehydration can overstress the kidneys and create problems. Another common misconception is that sweating correlates directly with weight loss; therefore, whirlpools, steam rooms, and sauna baths will aid in the goal of shedding excess pounds and, hopefully, fat pounds. As fitness professionals know, all weight loss from sweating is only temporary water loss that is replaced after eating and drinking. Many believe that the sweating and the opening of pores caused by these amenities will eliminate oil and dirt and, therefore, produce a more healthful and beautiful skin. True, temporarily, one may have cleaner skin; however, the water temperature of whirlpools, the heated humidity of steam rooms, and the dry heat of the sauna bath can wash away protective oils, dehydrate epidermis tissue, and result in skin that is both flaky and itchy. Although skin may have a reddened flush or glow after using a sauna, which is caused by the shunting of blood to the skin’s surface to dissipate heat, this apparent benefit of improved skin tone is short-lived. Also, individuals with oily skin and acne may find their conditioned worsened because heat may stimulate even more oil production. In addition to the fallacies of intentionally working up a sweat to eliminate toxins, lose weight, or improve skin tone, there are a number of serious health concerns when using these amenities. Whirlpools, steam rooms, and sauna baths are all subject to bacterial contamination that can cause numerous ailments, some of which may be life threatening.Although whirlpools or hot tubs may contain a high chlorine content, it is difficult to maintain bactericidal levels of dissolved chlorine gas in hot water that will have a negating effect on contaminating organisms. Jane Brody, a long-time science and health writer for The New York Times states that, “The most common disease-causing contaminant in whirlpools, steam rooms, and the like is Pseudomonas aeruginosa, a bacterium that thrives in a warm wet environment rendered highly organic by the debris from people’s bodies. The superficial showers most people take before entering a hot tub are not adequate to reduce the risk of contamination (5).” In hospitals, P. aeruginosa has been known to cause blood, pneumonia, and postsurgical infections among people with suppressed immune systems, infections that have led to severe illness. Nonetheless, apparently healthy people also are subject to developing illnesses when exposed to this contaminant (7). Ear and eye infections along with skin rashes are most common with this population. However, when elderly and at-risk individuals with depressed immune systems use a facility’s whirlpool or hot tub, they may be placing themselves at risk for more severe illnesses. Another bacteria (Mycobacterium avium) can thrive in whirlpools or hot tubs because the high water temperature neutralizes the chlorine. The bacteria can ascend with the steam and then be inhaled giving rise to the term “hot tub lung.” The resultant infection causes the afflicted to have fevers, cough, and shortness of breath (6). Those using outdoor hot tubs are less likely to develop this condition because the steam dissipates more rapidly in open spaces where the air is not so stagnant. Although herpes simplex is usually spread by sexual contact, researchers have become more concerned about its transmission through other sources such as water in hot tubs. A report in the journal from the National Institutes of Health indicated that, although the virus could only survive for about 15 minutes in hot (100°F) chlorinated water, it was able to survive for more than 4 hours on the plastic surface of a hot tub (10). Many males have heard that repeated immersion in hot tubs might impair a man’s fertility by heating the testicles to the extent that sperm production is reduced severely. Paul J. Turek, M.D., professor in the University of California-San Francisco Department of Urology and director of the Male Reproductive Health Center, conducted a study in which it was documented that total body exposure to wet heat impaired sperm production and motility (4). The study also found that the negative effect of this exposure was reversible in nearly half of the infertile men who discontinued this practice. Health hazards of a steam room also include dangerous bacteria such as methicillin-resistant Staphylococcus aureus, or MRSA, which thrive in the hot humid atmosphere of this tiled room. A Livestrong article notes that, “Although the tile surfaces of steam baths are easy to clean, highly trafficked public steam baths can be hotbeds for communicable illnesses (3).” As MRSA is typically spread through direct physical contact with contaminated objects like steam room benches, the skin, especially cuts and scrapes, must be kept clean and free from direct contact with these seated areas. Most sauna baths maintain temperatures of approximately 200°F. Again, these temperatures provide a breeding ground for the bacteria P. aeruginosa that can invade hair follicles of the skin, leading to folliculitis. Typical symptoms include itchy red bumps that often are pus filled and abscessed. In addition, individuals may be afflicted with a sore throat, chills, fever, nausea, and cramps (2). Another illness found among those using sauna baths has been a syndrome referred to as “sauna bather’s lung.” This results from sauna water buckets that are not washed and refilled on a daily basis and consequently lead to stagnant and contaminated water being poured over the hot rocks. The contaminated steam/air is inhaled, causing an allergic lung disorder, hypersensitivity pneumonitis. Typical symptoms may include chills, fever, coughing, fatigue, and an undesirable type of weight loss (5). As discussed, whirlpools, steam rooms, and sauna baths have no real health benefits other than temporary relaxation. Besides generating unsanitary conditions, they also burden facility management with maintenance headaches. They not only become a financial burden but also pose one of the highest risks to member safety in facility operations and consequent potential for litigation. Locations where supervision frequently is lacking include locker rooms and those areas where we find these heat exposure amenities. All too often, members develop cardiovascular complications in the locker room, and the only people likely to be present, if any, are other members; therefore, a locker room attendant should be available at all times, an attendant who can be providing housekeeping chores while simultaneously monitoring members. Likewise, it is not uncommon to witness whirlpools, steam rooms, and sauna baths completely unattended while being used by only one member (1). There are numerous anecdotal reports and documented cases of people having died while in whirlpools, steam rooms, and saunas. In fact, this author served as an expert witness in a case where an elderly gentleman with diabetes, hypertension, hyperlipidemia, and atrial fibrillation passed away while in an unattended whirlpool. These areas not only should be under constant surveillance but also should have signs posted that warn of the potential dangers, especially to high-risk members such as those with heart disease, diabetes, and high blood pressure. In addition to limiting exposure time, there are numerous cautionary notes to be posted on signage, such as “Do not use alone,” “Do not exercise within,” “Wait an hour after eating before use,” “Do not use while under the influence of alcohol, anticoagulants, antihistamines, or tranquilizers,” and “Do not use immediately after exercise” (1). Unfortunately, the time when whirlpools, steam rooms, and sauna baths are used most frequently in fitness facilities is shortly after exercise. On completing exercise, the body is undergoing a recovery process; but when one is exposed to the high temperatures of these amenities, blood is shunted or diverted to the skin to dissipate body heat and blood pressure, and, possibly, blood flow to the heart is decreased. For those with coronary artery disease, this can set the stage for angina and, in rare instances, a myocardial infarction or sudden cardiac arrest. For people with hard-to-control hypertension, the response to heat exposure may worsen blood pressure. In addition, many blood pressure medications interfere with the normal response of the body to heat exposure. Another concern is that people with hypertension should not move back and forth between these heated amenities and a cold plunge in the pool because this too can cause an exaggerated increase in blood pressure. Besides the sweating generated with these amenities, another misconception is that intentionally increasing the sweating response during exercise by overdressing (sweat suits) or exercising in a hot environment (e.g., Bikram yoga) also will help one burn more calories and lose weight. Again, the fitness professional recognizes that such activity serves no real purpose and, in fact, can become counterproductive. In reality, when the body overheats because of excessive clothing or warmer surroundings, individuals may decrease the intensity of exercise as they feel too “overheated” and thereby will decrease caloric expenditure. Another concern with a heated venue such as Bikram yoga is that the heated rooms may make ligaments excessively extensible, thereby encouraging ligamentous laxity and consequent joint hypermobility (11). A very serious concern is the use of sauna suits during exercise, rubberized suits that are even sold in some fitness facilities. To the layperson, the anticipated benefit of the sauna suit is that it will trap body heat and thereby raise the body temperature and thus cause the body to sweat profusely, which in turn leads to weight loss. However, this heated environment coupled with dehydration can create a cascade of potentially harmful effects, especially for one with the sickle cell trait. Documented dangers include rhabdomyolysis, kidney failure, splenic infarct, compartment syndrome (occurs when excessive pressure builds up inside an enclosed space in the body, usually results from bleeding or swelling after an injury), or death (9). During the stress of exercise, individuals with sickle cell trait have been recognized as being more predisposed to rhabdomyolysis and compartment syndrome than the average person. This risk is heightened with certain environmental conditions like altitude and hot humid weather. Heat and humidity obviously are generated in a sauna suit, which is its intended purpose. This author recently participated as an expert witness in a case for the plaintiff (Carter v. Burlington Coat), in which the plaintiff who possessed the sickle cell trait suffered both compartment syndrome and rhabdomyolysis as a result of exercising in a rubberized sauna suit. In this case, the cascade of harmful effects began with excessive sweating that led to plasma water loss. This dehydration led to hemoconcentration, increased blood viscosity, and a concomitant impairment of blood flow. This deprivation of oxygen led to erythrocyte sickling, which further led to oxygen and nutrient deprivation to overworked muscle, causing lactic acidosis. The excessive lactic acidosis damaged muscle membranes and allowed for the release of myoglobin into circulation, potentiating myoglobinuria and renal failure. This rhabdomyolysis led to swelling and compartment syndrome that in turn created more rhabdomyolysis (8). In addition, muscle injury or rhabdomyolysis can lead to electrolyte abnormalities such as hyperkalemia, potentially setting the stage for sudden cardiac arrest. Another potential effect is the development of disseminated intravascular coagulation, wherein proteins in the blood that normally form blood clots become overly active and thereby generate small blood clots throughout the circulatory system that block blood vessels and cut off oxygen delivery to organs such as the liver, brain, or kidneys (8). The dangers involved with sauna suits have been well documented for five decades. There are a plethora of articles and studies that document the dangers of sauna suits. However, although the individual anticipates weight loss through the wearing of a sauna suit, this is not the case. Typically, the public does not understand that this water weight loss is only temporary because it will be regained with food and drink. Nor does the public recognize that the temporary weight loss is not attributed to fat loss. Because of decreased intensity levels caused by overheating with the sauna suit, individuals actually end up burning fewer calories than anticipated. Promoting sweat loss beyond normal levels becomes not only counterproductive in weight/fat loss but also potentially dangerous. To the average person, the wearing of a sauna suit would appear not harmful or rather benign because of the fact that he or she probably has seen people wearing such suits as well as having read articles and advertisements with their misleading claims about weight loss and ridding the body of toxins. The fact remains that such suits are not effective in weight loss and do not provide a form of detoxification. Because of the fact that the public is generally unaware of the dangers of sauna suits, it is incumbent on the manufacturers of such suits to provide detailed and explicit warnings of the potential dangers. In addition, manufacturers should practice truth in advertising and explain that effective weight/fat loss is not a function of these suits, nor are suits going to rid the body of toxins. Truthfully, there is a very limited use for sauna suits such as for patients with psoriasis whose itching can be relieved by the use of ointments and by keeping the skin moist during inactive times. Because of the inherent dangers of sauna suits, many fitness professionals feel that they should only be made available by prescription for medical conditions such as psoriasis. As stated in previous columns, the no. 1 priority of any fitness facility should be the health and safety of its members. Consequently, previous articles have dealt with the concept of proper screening, such that all members receive a thorough health appraisal and then undergo fitness testing based on their medical history. In addition, members are to be provided with a program that is designed based on their health appraisal and fitness profile and then followed with attentive supervision to guarantee that programming is carried out safely and effectively. Should there be a medical emergency, the facility must have an emergency response plan that can be executed in an effective and timely manner. In line with this no. 1 priority, facilities that offer heated amenities must maintain the strictest hygienic standards. Members must be apprised of the limited benefits, misconceptions, and dangers of using whirlpools, steam rooms, and sauna baths. Most important, there must be supervision of these potentially dangerous areas. Regarding sauna suits, there is no place for their availability or use within fitness facilities. Not to understand the inherent dangers associated with these “hot topics” subjects facilities to litigation.