Swimming Causes Asthma

Larry Weisentha

The association of swimming with asthma has been long known.

But it has been a chicken/egg situation. The official "line" of USA Swimming (which has, shamefully,
turned its back on the problem) is that swimming is "good" for asthma (e.g. as discussed in the most
recent issue of SPLASH). Past articles in Swimming World have also endorsed the idea that swimming
(by being "good" for asthma) ATTRACTS asthmatics, rather than swimming CREATING asthmatics.

But the evidence which indicts swimming as the CAUSE of MOST cases of asthma present in competitive
swimmers is now overwhelming.

It is time to stop making excuses for the sport and to focus attention on this problem. Families
considering putting their kids in the sport must be informed in advance of the risks. Serious
investments must be made in (available) pool decontamination technologies to replace inexpensive but
toxic chlorination.

http://www-rohan.sdsu.edu/dept/coac...rine/asthma.htm

- Larry

Chris Lambert

Larry Weisenthal wrote:

> The association of swimming with asthma has been long known.
>

I suppose that is why many new pools are moving away from chroline then.

--
Chris Lambert (http://web.trout-fish.org.uk/) It has recently been discovered that research causes
cancer in rats.

Larry Weisentha

Chris Lambert (http://web.trout-fish.org.uk/)

>>It has recently been discovered that research causes cancer in rats.<<

1. Cancer is on course to shortly overtake heart disease as the number one cause of death
in the USA.

2. Most cases of cancer are "optional" and not "mandatory."

3. A not inconsequential amount of what we now know about the "optional" nature of cancer had
its genesis in or was supported by the causation of cancer in sub-human animal models,
including rats.

Ross Bogue

In <20031212164201.29482.00000007@mb-m02.aol.com> Larry Weisenthal wrote:
> The association of swimming with asthma has been long known.

I haven't studied your article carefully yet, but I fear it's not my favorite style of research
presentation. The sensationalist tone and lack of hard data seems to indicate that it's intended for
a general audience, not the usual readers of a research journal. Is this online journal a referreed
publication?

You summarized some interesting papers (Bernard, Aggazzoti, etc). Good! But you made a mistake
including some others. One in particular stood out:

... The implicated swimming pool revealed a gas-chlorinated pool with corrosion of metal
fixtures and etching of cement and a pH of 2.7.

I have no idea what this is doing in an article about asthma. This looks too much like a common
scare tactic. It is taking an isolated example of a very poorly maintained pool and pretending it
has some connection with the topic of the article. That sort of poor scholarship is usually a sign
that the rest of the article might not be entirely on the up-and-up.

Maybe it would help if you pulled that paragraph?

> But the evidence which indicts swimming as the CAUSE of MOST cases of asthma present in
> competitive swimmers is now overwhelming.

Maybe. I don't know. But a few limited studies and anecdotes do not establish anything as the "CAUSE
of MOST" of anything. And the leap from "exercise-induced bronchospasm" to "MOST cases of asthma" is
hardly intuitive. Is anyone looking into a larger study?

I almost hate to bring it up, but I didn't see where you discussed the relative cost of alternative
water treatment methods. What would be the costs involved? In this day when schools (my local high
school, anyway) are looking for excuses to shut down pools, you shouldn't avoid that discussion.

Ross

Larry Weisentha

To Ross,

You raise some excellent points. I'll address them this weekend. Thank you for taking the time to
read and consider.

- Larry

Larry Weisentha

Ross Bogue raises appropriate questions.

Firstly, some background.

I first raised the issue of asthma on this newsgroup about 5 years ago. At that time, approximately
8 of 25 kids on the Golden West Swim Club senior team were on inhalers for asthma. Then the pool was
changed from a chlorination system to an ozonization system. All 8 asthmatic swimmers were able to
discontinue their inhalers. I reported this on this newsgroup and received a private e-mail from the
assistant coach of the Santa Barbara Swim Club, which trained out of both a chlorinated pool (on the
beach in downtown Santa Barbara) and at an ozonated pool (at UC Santa Barbara). The coach told me
that, like on most clubs, there were many swimmers in the chlorinated pool on inhalers, but none in
the ozonated pool. I also received an e-mail from a swim parent in New England, who reported the
opposite to our Golden West Swim Club experience. The New England team changed from a chlorine-free
disinfection system to a chlorine-based system. Where asthma had been previously unknown on the team
prior to chlorination, asthma became a serious problem thereafter. I also received an e-mail from
former US Olympic Silver and Gold medalist, David Berkoff. Berkoff had also been concerned about the
health hazards to competitive swimmers of swimming in chlorinated pools. He participated in a
research project which resulted in a peer-reviewed publication (quoted in our editorial). Berkoff
put great effort into trying to get USA Swimming to take the issue seriously and to support further
research. He was very disappointed when these efforts were not successful.

Also at this time, an international caliber swimmer (Pan Pac medalist) joined the Golden West Swim
Club. This swimmer had a long history of serious, intractable, steroid-dependent asthma. I told the
swimmer's parents that there was every likelihood that the swimmer's asthma would disappear, once
she began training in the GWSC ozonated pool. I was correct. Within two months, the swimmer was off
all medications.

Two years ago, my older daughter, who at the time had been a competitive swimmer for 10 years,
developed asthma while training at the University of California Irvine pool, which was an outdoor
pool with very high walls (which trap chlorinated air at the water's surface well below deck level,
particularly on cold mornings). This required treatment with inhaled glucocorticoids and
bronchodilators. She developed continual and nearly intractable coughing and wheezing (which
resulted in literally thousands of dollars in related medical expenses). She spent 6 months last
year in England, training in an indoor, chlorinated pool, where the asthma worsened further. She had
several very severe acute episodes and, in addition to bronchodilators, carried an emergency
epinephrine syringe at all times in her swim bag. This was "real" (not just exercise-induced)
asthma, with elevated serum IgE and eosinophilia. In late January, 2003, while on a three week
training trip with her British team to Australia, she developed a severe shoulder injury which kept
her out of the water for 6 months. Her asthma completely disappeared and she discontinued all
medications. Since September, she has resumed full time training in an indoor pool as a college
freshman varsity swimmer. Her asthma has recently begun to recur.

These anecdotes are familiar to anyone closely involved with competitive swimming; were they only
anecdotes, the situation would, perhaps, merit the benign neglect of USA Swimming. But these are not
isolated anecdotes, as our editorial notes and which swim coaches would not dispute.

Bogue raises several questions.

First, the paper was an invited editorial and was reviewed only by the journal editorial staff and
was not peer-reviewed.

Second, the writing style was intentionally confrontational. The paper was an editorial and not a
review. It was squarely addressing the same concerns raised by US Olympic medalist David Berkoff
15 years ago, which have continued to be ignored by the governing bodies of national and
international swimming.
Dr. Rushall and I feel that the short and long term health of literally tens of thousands of
children is being jeopardized needlessly (as there are available decontamination alternatives,
discussed in the editorial, which are not being explored with the deserved urgency).

With regard to the so-called lack of factual data, the following are the important points:

Firstly, it is precisely because of the publication of the recent (since year
2000) published studies that the editorial is particularly timely. In particular, the year 2002
study from Finland is of compelling importance. The authors documented a high level of asthma
in competitive swimmers. This confirmed may previous studies which are disputed by no one.
However, in the Finnish study, the authors followed the swimmers for several years after
enrollment into the study. Swimmers who continued to train had a progressively increasing
level of asthma. In athletes who discontinued swimming, asthma spontaneously disappeared in
the majority.

These findings, in the context of all the pre-existing information, including the near universal
experience of professional coaches, makes an overwhelmingly case to support our point of view, that
the lack of attention to this serious problem is "deplorable."

Of course additional research would be helpful. Berkoff tried to get USA Swimming to support such
research 15 years ago, without success. Tens of thousands of children have since suffered the
consequence of swimming-induced asthma in USA Swimming sponsored programs ever since then. It is
inexcusable and reprehensible that USA Swimming would not only fail to take a proactive role in
addressing and solving this problem, but instead would continue to provide false assurance (e.g. as
in the current issue of Splash) that swimming has a mitigating, rather than a causal, effect
relating to asthma.

Regarding the cost of chlorination alternatives, these costs must be balanced against the medical
expenses related to treating asthma, which are considerable, as my own family's experience
documents.

The following study further emphasizes this point:

Med Klin (Munich). 1996 Oct 15;91(10):670-6.

Cost of asthma therapy in relation to severity. An empirical study

Graf von der Schulenburg JM, Greiner W, Molitor S, Kielhorn A.

Institut fur Versicherungbetriebslehre, Universitat Hannover.

BACKGROUND: The aim of asthma therapy, i.e. the permanent elimination of the patient's symptoms, is
as a rule, achievable over the long-term only with the aid of anti-inflammatory drugs. As well as
medical, this approach also has considerable economic implications. The comparatively low compliance
among asthmatics makes treatment in this context all the more difficult. An alternative that
presents itself is the use of combination preparations, a mixture of a long-term prophylactic and a
therapeutic agent. PATIENTS AND METHODS: With the aid of standardised questionnaires, data were
acquired from 216 patients and assigned to subgroups in accordance with the degree of severity of
the asthma. The patients were treated in the offices of a total of 23 GPs and internists selected at
random from a complete list of all relevant practices in Germany. The use of resources, i.e. all
diagnostic and therapeutic measures, was recorded retrospectively for a period of 1 year. In this
way, all those resources of relevance to the health insurance carriers used during the observation
period were identified. In addition to direct costs, so-called indirect costs were also estimated,
i.e. in the present study the productivity loss to the economy due to illness-related absence from
work. RESULTS: The annual cost of treating adult asthmatics was calculated to be DM 3,339 for level
1 severity, DM 5,260 for level 2 severity and DM 12,016 for level 3 severity. As the illness
progresses in particular the direct cost of inpatient care and the indirect costs rise
disproportionately. The yearly expenditure for women sufferers is about DM 800 more than for male
sufferers. The direct cost of asthma treatment in children amounts to DM 2,950 for level 1, DM 3,225
for level 2, and DM 4,811 for level 3, severity. Here, drug-related costs in particular, rise
significantly as the disease progresses. CONCLUSION: One of the results of the present study is the
fact that for asthma sufferers in general, there is a positive correlation between average total
costs and degree of severity. It may thus be postulated that preventive medical treatment of asthma
that slows the progression of the illness, together with appropriate patient instruction, would have
a positive effect on the total expenditure per patient. If, for example, the appropriate use of
drugs in combination with patient instruction improved the compliance of asthmatics, lower treatment
costs and a better quality of life for the patient could be expected.

>>>

The above costs (much of which is related to the cost of prescription drugs) are undoubtedly lower
in German than in the USA (and the above study was published 7 years ago, and must be adjusted for
inflation and the introduction of newer and more expensive drugs and diagnostic tests).

With regard to the seemingly unrelated issues of dental erosions and cancer, it was the intention of
the authors to focus attention on the problem of training for hours per day in chlorinated pools,
and it seemed appropriate to note that there were additional medical issues beyond asthma to be
considered. In particular, the long term carcinogenic effect of intense exposure to chloramines
deserves much more attention than previously received.

It must further be noted that the long term consequences of treating childhood asthma include long
term effects such as osteoporosis and cataracts. e.g.

J Allergy Clin Immunol. 2003 Sep;112(3 Suppl):S1-40.

Inhaled corticosteroids: past lessons and future issues.

Allen DB, Bielory L, Derendorf H, Dluhy R, Colice GL, Szefler SJ.

Division of Endocrinology, University of Wisconsin Children's Hospital, Madison 53792-4108, USA.

Inhaled corticosteroids play a pivotal role in the treatment of asthma. Inhalation permits effective
delivery of the corticosteroid in high concentration to target sites within the lung while
minimizing systemic exposure. Consequently, the safety profile of inhaled corticosteroids is
markedly better than that of oral corticosteroid therapy. However, although it was first thought
that direct delivery might eliminate systemic adverse effects, this has not been confirmed by
clinical trials and experience. Inhaled corticosteroids are absorbed from the lungs into the
systemic circulation, in which they can acutely decrease growth velocity in children, an effect that
fortunately appears to be temporary and might have no effect on final adult height. In sufficient
dosages, they also produce bone mineral loss leading to osteoporosis and might increase the risk of
cataracts, glaucoma, skin atrophy, and vascular changes that increase the risk of ecchymoses.
Effective evaluation of the severity and significance of these complications is challenging because
highly sensitive tests do not reliably predict clinically significant events, and short-term
observations do not predict long-term consequences. Also, compliance wanes with long-term treatment,
and susceptibility to a particular adverse event can vary over time, even in the same individual,
because of developmental or hormonal changes. This journal supplement will review what has been
learned about the safety of inhaled cortico-steroids during the past decade, discussing some of the
questions that remain and considering the characteristics of an "ideal" inhaled corticosteroid: one
with high local activity in the lung and minimal or no adverse systemic effects.

>>>

It is important to emphasize that, by far, the highest risk group are children and teenagers in year
around competitive swimming programs. These swimmers have a vastly greater exposure to chloramines
than in the case of recreational and masters swimmers. Additionally, growing children have greater
vulnerability to the long term health consequences of intense exposure to chlorinated pool water.

It is past time for the competitive swimming community to address and solve this important issue.
Hopefully, it will not take something like a class action lawsuit to initiate the needed actions,
which, at a minimum, require disclosure of risks and informed consent from parents who expose their
children to these risks.

- Larry Weisenthal

Pat

"Larry Weisenthal" > The association of swimming with asthma has been long known.

Is this only a chlorine problem? I swim in a bromine pool. I haven't had any bad effects from it,
but then, I don't "train" like the competitive swimmers. Have you heard of this asthma problem with
bromine pools?

thanks,

Pat in TX

Colin Priest

Swimming attracts asthmatics. When was diagnosed with asthma my doctor's first comment was that I
should take up swimming to treat it. My personal experience is that swimming controls my asthma
better than any medication, but it just happens that I swim outdoors in a salt water pool. A couple
of weeks ago I saw an interview with Samantha Riley on TV in which she said that swimming had kept
her asthma under control and she told of some instances when she had stopped training and her asthma
had subsequently become worse.

Your article is dangerous. It could discourage asthmatics from swimming and benefiting from the
resultant improvement in asthma symptoms, all without side-effects.

"Larry Weisenthal" <runnswim@aol.comnet> wrote in message news:20031212164201.29482.00000007@mb-
m02.aol.com...
> The association of swimming with asthma has been long known.
>
> But it has been a chicken/egg situation. The official "line" of USA
Swimming
> (which has, shamefully, turned its back on the problem) is that swimming
is
> "good" for asthma (e.g. as discussed in the most recent issue of SPLASH).
Past
> articles in Swimming World have also endorsed the idea that swimming (by
being
> "good" for asthma) ATTRACTS asthmatics, rather than swimming CREATING asthmatics.
>
> But the evidence which indicts swimming as the CAUSE of MOST cases of
asthma
> present in competitive swimmers is now overwhelming.
>
> It is time to stop making excuses for the sport and to focus attention on
this
> problem. Families considering putting their kids in the sport must be
informed
> in advance of the risks. Serious investments must be made in (available)
pool
> decontamination technologies to replace inexpensive but toxic
chlorination.
>
> http://www-rohan.sdsu.edu/dept/coac...rine/asthma.htm
>
> - Larry

Larry Weisentha

>>Is this only a chlorine problem? I swim in a bromine pool. I haven't had any
bad effects from it, but then, I don't "train" like the competitive swimmers. Have you heard of this
asthma problem with bromine pools?<<

That's an important question...would be so easy to answer so many important questions relating to
the association between swimming and asthma, were USA Swimming simply to send out some well-designed
questionnaires to its 250,000 or so member swimmers.

For what it's worth, the anecdote I gave of the New England swim club which switched from a non-
chlorine disinfection system to a chlorine-based disinfection system (and went from basically no
asthma to a lot of asthma) switched from bromination to chlorination. So it may be that bromination
is safer, from an asthma perspective; but research (currently not being done, but relatively easy to
do, as noted above) is needed.

Ross Bogue

In <20031213005852.21823.00000580@mb-m19.aol.com> Larry Weisenthal wrote:
>
> These anecdotes are familiar to anyone closely involved with competitive swimming; were they only
> anecdotes, the situation would, perhaps, merit the benign neglect of USA Swimming. But these are
> not isolated anecdotes, as our editorial notes and which swim coaches would not dispute.

It sounds to me like you want USA Swimming, FINA, and perhaps some other bodies to collectively
sponsor a symposium on the subject. You, Rushall, and others would present your findings, and the
entire body would decide whether it deserves further study or whether to recommend a change in the
current practice.

Do you have any supporters in those groups who might propose such a symposium?

>
> Regarding the cost of chlorination alternatives, these costs must be balanced against the medical
> expenses related to treating asthma, which are considerable, as my own family's experience
> documents.

Well, what are the costs?

The costs of treating asthma would be borne by the swimmers' families, not the parks and schools
that own the pools. The relevant question is "Do we upgrade this already-too-expensive pool, or do
we close it down and divert any money into the football program?" Remember that the school is
currently $2 million in the red (yes, my local school is), and that the board members' children are
in football, not swimming.

Ross

Bill

runnswim@aol.comnet (Larry Weisenthal) wrote in message news:<20031212164201.29482.00000007@mb-m02.aol.com>...

> But the evidence which indicts swimming as the CAUSE of MOST cases of asthma present in
> competitive swimmers is now overwhelming.
>
> It is time to stop making excuses for the sport and to focus attention on this problem. Families
> considering putting their kids in the sport must be informed in advance of the risks. Serious
> investments must be made in (available) pool decontamination technologies to replace inexpensive
> but toxic chlorination.
>
> http://www-rohan.sdsu.edu/dept/coac...rine/asthma.htm
>
> - Larry

I read about swimming and asthma a few years ago but not exactly in the "toxic" laden tone of this
article. This article as it is, would do more harm than good. It is sensationalized rumor-mongering
hiding behind bibliograhic references but actually is based on nothing more than a few casual
observations. Anybody can put 2 and 2 together and come up with 5.

I was an asthmatic as a young child and remember being rushed to the hospital a few times. However,
by the time I turned 20, I had completely outgrown it. I am 40 now, and have been swimming in
chlorinated pools 3-4x a week for about 1 to 1.5 hrs each session for the past 10 years. My hair is
brittle and my skin reeks of chlorine all day long, but the asthma has stayed away. Thanks to
swimming, I'm slim and trim. If I had read this article 10 years ago before I took up swimming, I'd
be a couch potato with a 40-inch belly by now.

Bill

Diablo

"Larry Weisenthal" <runnswim@aol.comnet> wrote in message
news:20031214221404.11589.00000606@mb-m25.aol.com...

So it may be that bromination is
> safer, from an asthma perspective; but research (currently not being done,
but
> relatively easy to do, as noted above) is needed.

and who do you propose finance this research? we both know it would take much MUCH more to verify
this than 250K questionnaires, of which you might get a return of 33%?

and then what? who will stump up the money for renovation of the pools to meet the specified
requirements? we're lacking pools of a high standard anyway, and struggle to find money for more.

also, to suggest that people select their club on this basis is a little far fetched don't you
think? as salient as your point may be, i very much doubt anyone would follow that advice.

MSEagan

I know of many cases where bromine facilities had to switch to chlorine because too many people
developed severe contact dermatitis from the bromine. Chlorine worked fine. I also knew of at least
one kid who had more asthma in bromine than in chlorine.

Ozone would be nice, but then I am told that it only works as the water is filtered through the
system but does not help with immediate disinfection, for example, if the person next to you has a
runny nose with infected mucous and you happen to swallow it (yuck). Chlorine works on contact to
kill this sort of thing.

Ventilation would certainly help, but what do we do about all those old facilties that many are
stuck using? What really irks me is our local YWCA has the air SO hot and humid (and the water) and
they refuse to open doors for ventilation. If there is some literature on this, I would like to pass
it along to them in the hopes that maybe they will come to their senses. Marianne

"Larry Weisenthal" <runnswim@aol.comnet> wrote in message news:20031214221404.11589.00000606@mb-
m25.aol.com...
> >>Is this only a chlorine problem? I swim in a bromine pool. I haven't had
any
> bad effects from it, but then, I don't "train" like the competitive swimmers. Have you heard of
> this asthma problem with bromine pools?<<
>
> That's an important question...would be so easy to answer so many
important
> questions relating to the association between swimming and asthma, were
USA
> Swimming simply to send out some well-designed questionnaires to its
250,000 or
> so member swimmers.
>
> For what it's worth, the anecdote I gave of the New England swim club
which
> switched from a non-chlorine disinfection system to a chlorine-based disinfection system (and went
> from basically no asthma to a lot of asthma) switched from bromination to chlorination. So it may
> be that bromination
is
> safer, from an asthma perspective; but research (currently not being done,
but
> relatively easy to do, as noted above) is needed.

Brian D

On 15 Dec,
"MSEagan" <swimgiraffe@yahoo.com> wrote:

> Ozone would be nice, but then I am told that it only works as the water is filtered through the
> system but does not help with immediate disinfection, for example, if the person next to you has a
> runny nose with infected mucous and you happen to swallow it (yuck). Chlorine works on contact to
> kill this sort of thing.
>
Our main pool is mainly ozone disinfected in the circulation system (which is then filtered out) and
is about 20 years old It uses a small chlorine dose for immediate disinfection (about 25% of the
usual dose) of the bulk water to kill the above. More modern pools often use UV tubes as the main
steriliser, but still use a small chlorine dose. All pools backwash their sand filters at least once
a week which serves to dilute the combined chlorine and TDS in the pool, which can be a major
problem if not kept in check.

I personally find the perfumes/deodorants and shampoo used by swimmers a greater allergin. I have
hay fever which has developed to asthma on a few occasions, non athletic, but when there have been
high levels of the trigger allergins about. This has never been when swimming in any pool, which has
always been beneficial to me.

--
BD add 1 to from address to reply [13435]