Hot Tub Therapy For People With Diabetes

This article was originally published in Diabetes Health in August, 2008.

Lowers BGs, But Is It Safe?

| May 23, 2008

Is it possible that a dip in the hot tub can cause a dip in the blood sugars? According to a pilot study that appeared in the September 16 issue of The New England Journal of Medicine (NEJM), "hot tub therapy" helped a group of type 2s reduce their blood sugars, lose weight and improve sleep patterns.

Philip L. Hooper, MD, of the McKee Medical Center in Loveland, Colorado, studied five type 2 men and three type 2 women, ages 43 to 68. The patients had been suffering from diabetes from three to 14 years.

"These results suggest that hot tub therapy should be further evaluated as a therapy for patients with type 2 diabetes mellitus," says Hooper. "It may be especially helpful for patients who are unable to exercise."

23 mg/dl Reduction in BGs

The temperature of the hot tub water went as high as 104 degrees Fahrenheit. The type 2 subjects sat in the hot tub by themselves with water up to their shoulders for 30 minutes per day, six days per week, for three weeks. The patients' average blood glucose (BG) levels were reduced from 182 mg/dl to 159 mg/dl after three weeks, while HbA1c was reduced from an average of 11.2% to 10.2%. Weight was decreased by an average of 3.75 pounds.

In an interview with Diabetes Health, Hooper explained how one of the study participants, after 10 days, reduced his daily dose of insulin by 18 percent. Another subject, however, showed no reduction in her HbA1c.

"I asked her how her three weeks had gone," Hooper explains. "She said she had a terrible three weeks. Her coworker had quit, her house had gone up for sale and her daughter had a complication in her pregnancy. She said the only quiet time in her day was when she was in the hot tub. In other words, during the study, she was under emotional stress, which will increase blood sugars. Hers, however, stayed the same."

Hooper adds that two other subjects weighed more than 375 pounds, but found their bodies felt much better after three weeks of hot tub therapy.

"Most subjects found that their blood sugars went back up two to three weeks after stopping the study," says Hooper.

Better Exercise Than Swimming

Hooper feels that this study may explain why HbA1cs are better in warm months and worse in cool months.

"I had assumed that the mechanism might be as simple as increasing blood flow to skeletal muscles, which accounts for 80 percent of the insulin-mediated glucose uptake in the body," he says. "However, as I learn more about such issues as heat conditioning and heat shock proteins, it may be more complicated than an increase in blood flow."

Hooper adds that the study may also explain why swimming, which seems like such a good exercise, does not help as much as one would think in terms of BG control or weight loss.

"Swimming does not 'warm' the body," he says.

What About a Hot Bath?

Hooper feels that taking a hot bath could also have the same positive effects as hot tub therapy, but a test would have to be conducted in the same fashion as this study.

"If getting into a hot bath actually raises the body temperature 1 degree Fahrenheit, if immersion to the neck is not important, and if the temperature of the water is kept at 102 to 104 degrees Fahrenheit, then I would speculate that a hot bath would work," says Hooper. "I do have a concern that patients with neuropathy in their legs could burn themselves if they didn't actually check the temperature with a thermometer prior to entering."

Tina, a type 1, writes over the Internet that taking a hot bath is very enjoyable, but makes her BGs go low very quickly.

"I have found that when taking very hot baths, if my BGs are on the way down, like before a meal, the hot bath makes them go very low very quickly," she says. "If my insulin has already peaked, however, the hot bath will cause my BGs to skyrocket very quickly."

Hooper warns that patients taking insulin are also at risk of going too low later in the day or night. He recommends eating a bigger snack before bed or reducing your insulin dose by 5 to 10 percent, assuming that one is getting in the hot tub in the evening.

Are Hot Tubs Safe For People With Diabetes?

Richard Bernstein, MD, FACE, FACN, of the Diabetes Center in Mamaroneck, New York, says that a person with diabetes who sits in a hot tub is "just asking for trouble."

"People with the condition often have nerve damage in their feet, which means they can't feel their feet, so they are likely to get burned...yet feel no pain at the time," says Bernstein, who adds that exercise, weight loss and medications are better ways to lower insulin resistance.

Hooper explains that he has the same concern for people with neuropathy and suggests that they could very well burn themselves if they do not actually check the temperature before entering the hot tub.

Tammy Villanueva, a type 1, writes over the Internet that she notices a drop in her BGs after sitting in a hot tub for more than 15 minutes or a hot bath for more than 30 minutes. She says her biggest concern is passing out after getting out of the hot tub.

"I never notice the signs of lower blood sugars until after I get out of the hot tub," says Villanueva. "The relaxation can mimic the low."

Hooper admits that blood pressure also drops when exiting a hot tub. For his study, participants were assisted from the hot tub and offered a bench to sit on. Hooper says people with diabetes should always exit the tub slowly and perhaps with assistance.

Joan Hoover, Diabetes Health's patient advocate advisor, is surprised at the suggestion that hot tubs might be beneficial for people who have type 2 diabetes.

"Every public hot tub I've ever seen, in hotels and Y clubs, has a warning sign to caution pregnant women, people with diabetes and other people who have high blood pressure," says Hoover.

Hooper says that patients who hot tubbed in the morning found they were rather 'washed out' afterwards. He adds that they quickly learned to hot tub in the late afternoon or evening.

"They then slept better and felt better," he says.

Sarah Elliott of Three Rivers, California, is the mother of an 8-year-old, type 1 boy. When her son was diagnosed in April 1998, she heard all the horror stories about diabetes, but only one stuck in her mind.

"It was about a 14-year-old boy with type 1 diabetes who died in his hot tub," she recalls. "Apparently, this boy had come home from a football game, went into the hot tub and was found dead. I told my concerns to our diabetes educator and she informed me that the boy had most likely drowned after going too low and passing out."

When Elliot heard about this, she concluded that her son could never sit in a hot tub unsupervised, no matter what his age.

"That way, if an incidence of low blood sugar does occur, he can be assisted out of the water, in case he can't do it himself," she says.

Hooper admits that patients taking insulin "are at risk of going low with their blood sugar later in the day or night if they have hot tubbed."

Helen Germann of Plano, Texas, points out that approximately 40 percent of people with diabetes die from heart problems. In addition to having diabetes, Germann has tachycardia, or rapid beating of the heart, and feels that hot tubs can aggravate that condition.

"I wouldn't try this kind of 'exercise' without a doctor's okay," says Germann, adding that people with diabetes also tend to have dry skin, and sitting in a hot tub for this length of time could create skin problems. She also points out that chlorine could affect dry skin. "I've been told to take only short, warm showers and use lots of lotion."

Is it Fun?

Diane Pearson, RN, CDE, founder of Diabetes Care Consultants in San Diego, thinks that socialization might be another component that contributes to a person's BG control.

"This study didn't mention what went on the hot tub," she says. "Did subjects chat with one another? Did they discuss their problems? Offer encouragement?"

Hooper explains that patients in the study did not overlap their visits with one another, so there was no socialization, other than with employees at the testing facility who welcomed them and helped them out of the hot tub afterwards.

"Patients seemed to enjoy the pause in their day when they 'had to' go sit in the hot tub," says Hooper. "It provided a break in their routines and gave them time to themselves. I do not underestimate that there were some real psychological benefits to getting into the tub."

Joseph Prendergast, MD, president of Diabetes Advocates in Atherton, California, says that Hooper's NEJM study may be the best science we will ever see on this situation.

"But, it may well be useful, if only to give patients something fun to do rather than an inappropriate lifestyle," he says. "It is a good thing for most patients hoping for more spiritual improvement rather than medical."

Joan Hoover also feels that if hot tub therapy does no harm, it is probably the nicest therapy ever recommended to people with diabetes.

"People with diabetes are usually asked to do miserable deeds like inject, bleed, diet and exercise," she says.

Nurse Recommends Other Therapies

Margaret Wilkman, RN, MPH, CDE, thinks hot tub therapy is an interesting notion, but would not recommend it.

"I wonder if these patients would have achieved the same benefit if they practiced mindful meditation or biofeedback for 30 minutes, three times a week," says Wilkman, who recommends other exercises for type 2s who do not have the capacity for higher impact forms of exercise. "Water aerobics and armchair exercises may offer beneficial forms of exercise for patients who do not tolerate the impact of walking or jogging."

Prendergast adds that many patients have told him that they get improved glucose control with deep massage.

"They have said that they feel it is due to increased circulation to the muscles," he says. "Could this be what the hot tub did for those in the study?"

Future Studies

Hooper is in the process of writing a grant for further research in this area from the National Institutes of Health, the American Diabetes Association and possibly the American Heart Association. He says many questions have been raised by this study, including what the long-term effects will be on blood sugar control, weight, blood pressure, lipids, well-being, exercise conditioning and heat tolerance?

"My study was a pilot study, which was published in order to provide a new thought in the management of diabetes," says Hooper. "It cannot be endorsed as an 'approved' method of therapy at this time."

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Posted by Anonymous on 1 November 2007

I have been struggling for months now with raised fasting blood sugar in the mornings, but each time have spent 20 minutes in the evening in the hot tub, it has been between 5 -5.5, I plan to make this part of my daily routine.

Posted by Anonymous on 3 February 2008

I can check my b/s and it be really high like in the 500's and i get in a tub of hot water and sit for 30 minutes or longer and when i get out they drop to 169. My insulin does not help when i take it nor does my metformin but taking a hot bath does every time. I was wandering why that is but now after readin this article i understand.

Posted by Anonymous on 24 February 2008

I don't know about blood sugar, but my BP drops up to 40 points after getting out of the hot tub. I've just gotten on medication, and my BP is still fairly high, averaging about 140/95. After a dip in the hot tub, it drops as low as 100/60, but 110/70 is more typical. A long hot shower works almost as well.

Posted by Anonymous on 22 May 2008

A word of caution: most spa hot tubs have very heavy chlorine content. There you are, in hot water with open pores, sitting in a vat of what amounts to a poison. No immediate effects, but over the long term such concentrated exposure to chlorine is not a good idea.

Posted by Anonymous on 23 May 2008

Diet, I mean proper food and moderate exercise, I lost 30 LBS In a year and got off all meds, BP Pills and Metformin!!! Don J Ontario

Posted by Anonymous on 23 May 2008

Wow- this is way cool, or maybe I should say hot! I have an indoor hot tub in our house. What a good reason to use it more often. I will try testing BS before and after using it and dee if it makes a difference.

Posted by mjensentulsa on 23 May 2008

I almost laughed when I read the statement, "Every public hot tub I've ever seen...has a warning sign to caution pregnant women, people with diabetes and other people who have high blood pressure."

People who live with diabetes learn pretty early on to ignore such signs, as they appear on virtually every over-the-counter medication, every activity that raises the heartbeat, every bit of fine print that a lawyer can get his hands on. Those words, we understand, are there to protect someone else (i.e. the spa owner, the pharmaceutical company), not us. We have to learn the real story about what is safe and what isn't, and why, and a sign on the wall is perhaps the most untrustworthy source of such information.

Likewise the doctor who thinks diabetics are too stupid to protect themselves from jumping into a pot of boiling water. Where is the study that documents such a threat? If hot tubs were indeed turning people into boiled frogs (diabetic or otherwise), we would read about it in the newspapers. Then those happy lawyers would rush in and win awards that would get the manufacturers to turn the heat down (pretty sure this happened already), and, oh yeah, post a sign overhead, disclaiming further responsibility.

Diabetics need to live and move in the real world, not the paranoid universe of these so-called experts. Find the evidence to support your silly restrictions or quit the fear-mongering, please. You will be doing us all a service.

Posted by Anonymous on 23 May 2008

Read the last paragraph!!!
this is a PILOT study, not definitive and it was published in 1999. Let's have other studies with more people before we take this study seriously!

Posted by mjensentulsa on 25 May 2008

And I found the graphic adjoining this article particularly amusing. The older couple in the tub being observed by a professional-looking guy in street clothes. Perhaps, in order to ensure strict observance with the "Never Bathe Alone" signage, we need a new class of caregiver: The Certified Diabetic Bathing Advisor. CDBA's could hang out at the Y with their thermometer and whistle. "It's 104.5. TWEET! Type 1's! Type 2's! Out of the pool!"

(In all fairness, I do try to comply with the guidance on that particular sign. I just prefer a more casual dress code, if you know what I mean....)

Posted by Anonymous on 29 May 2008

Perhaps, in order to ensure strict observance with the "Never Bathe Alone" signage, we need a new class of caregiver: The Certified Diabetic Bathing Advisor. CDBA's could hang out at the Y with their thermometer!

Posted by Green Lantern on 27 June 2008

It's true that this study was done in 1999, and unfortunate that there isn't anything more recent. I met someone with Type 1 DM whose kidneys were failing 13 years ago--then her creatinine started dropping. The kidney doctor never knew why (um, didn't ask what she was doing...) but she was doing Native American sweat lodges twice a month! After each one, her BG would stay at 120 for a week--and her kidneys recovered. Now they are failing again, but maybe more sweat therapy will help slow that down. So, it's not just hot tubs; it could be that anything that raises core body temp. for a while, like a sauna, could also do the trick. Again, your mileage will vary, and having someone else on hand would be a good idea...

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