More Swimmers Will Result in a Healthier Society, Fewer Drownings and Reduced Healthcare Costs

By Thomas M. Lachocki, PhD

A white paper commissioned by National Swimming Pool Foundation® May 2012, reprinted with permission

Executive summary
The problem

• Physical inactivity, obesity, and an aging society are driving up healthcare and insurance costs. These epidemics continue to grow at an alarming rate.
• About 3,800 drowning deaths (almost 700 in pools), 5,700 emergency department-treated injuries (over 3,300 in pools), and hundreds of civil suits occur every year.
• About half of Americans have a fear of swimming pools.

The solution
Physical inactivity and obesity will continue to drive up healthcare cost as baby boomers pass 65 years of age and childhood obesity continues to increase. To stabilize and reverse these crippling trends, government and the private sector will have to invest to increase physical activity. Aquatic activity is ideal for sedentary, obese, and older populations. Yet, about half of Americans either fear deep water or cannot swim. Because so many cannot swim, aquatic activities that improve health and longevity are lost to approximately 100 million Americans—and those they influence. This aversion to water also places large populations at risk of drowning.

Fortunately, many extraordinary, financially-sustainable organizations have exceptional programs to attract and teach millions of people to learn to swim. In addition, one of the leading ‘aspirational activities’ for all ages is to swim for exercise. It is tragic that so many people who aspire to be swimmers—are not swimmers—yet.

The position
Pool, spa, and aquatic businesses, associations, healthfocused organizations, and government must commit to supporting organizations that teach people to swim. More swimmers will result in a healthier society, fewer drownings, and reduced healthcare costs, with an increased number of people engaged in a healthy spectrum of aquatic activities.

Inactive and aging society
Inactivity among Americans has resulted in catastrophic increases in obesity. Coupled with an aging society, the health consequences and associated costs are skyrocketing. Water’s buoyancy reduces stress on joints, risk of falls, and injuries. Water’s mass increases cardiac and respiratory exercise, making aquatic activity ideal for historically sedentary and aging populations.

Inactivity
The 2008 Physical Activity Guidelines for Americans¹ recommends that adults avoid inactivity. Some physical activity is better than none, and adults who participate in any amount of activity gain some health benefits. For substantial health benefits, the Guidelines recommend that adults perform at least 150 minutes a week of moderate-intensity aerobic physical activity, 75 minutes a week of vigorous intensity aerobic physical activity, or an equivalent combination of moderate and vigorous activity. Children and adolescents should perform 60 minutes or more of physical activity each day (Figure 1).

Figure 1.

Overall, approximately one in three American men and nearly 40 percent of women report no leisure time physical activity. However, there are definite race/ethnic differences, ranging from 30-33 percent in non-Hispanic whites and Asians to nearly 50 percent among non-Hispanic African Americans, Hispanic, or Latino Americans.

In 2011, only about 45 percent of Americans overall met the aerobic guidelines. However, prevalence ranges from about 65 percent in 18-24 year old men to little more than 20 percent in 75+ year old women.² US Census data indicates that the number of people over 65 years of age will increase by more than 23 million (from 40.2 to 63.9 million) from 2010 to 2025. The percentage of adults who met the activity guidelines decreased with age. These groups are ideal candidates to remain active, although most forms of activity—other than aquatic activity—are less suitable for these age groups (Figure 2).

Figure 2.

Obesity
Inactive (sedentary) lifestyles—and poor diet—have resulted in dramatic increases in obesity. In 1990, no state had greater than a 15 percent obesity rate. In stark contrast, by 2010, no state had an obesity rate under 20 percent. In 2010, twelve states had an over 30 percent obesity rate. The obesity trend is not showing signs of reversal. Since 1980, the obesity rate among children has tripled, with 17 percent (12.5 million) of children and adolescents between 2 and 19 years old being obese. The increase in childhood obesity is likely to have long-term health, financial, and social consequences (Figure 3).

Figure 3.

Financial consequences of obesity
Overweight and obesity are major factors in rising healthcare costs.³ The medical burden of obesity is estimated to be $147 billion/year. This cost has increased from 6.5 percent to 9.1 percent of annual medical costs. With the percentage of people over 65 and continued increases in child obesity rates, it is reasonable to expect that health care costs due to obesity will continue to rise for decades. A more recent study suggests that obesity rates will reach 42 percent-51 percent by 2030. Reducing obesity by 1 percent below the expected trend would reduce medical expenditures due to obesity by about $85 billion over that 20-year period.⁴ Thus, there are substantial financial drivers to encourage greater activity and improved diet.

To further illustrate the cost impact of obesity, a seven-year study of Mayo Clinic employees and family members compared health care cost for enrollees with normal body mass versus overweight enrollees.⁵ Each higher body mass index category had higher health care cost per year. The morbidly obese study participants had annual medical costs ten times higher than overweight study participants:

• Overweight    $382/year
• Obese    $1,850/year
• Morbidly obese    $3,086/year
• Morbidly obese II    $5,530/year

Inactivity, obesity, aging society and swimming
The social and financial consequences of mega-trends like inactivity, obesity, and aging are some of the largest that western society faces. Based on the needs of society and the research demonstrating health benefits from aquatic activity, it is important to understand factors that discourage and encourage more people to become competent and capable swimmers.

Barriers to having more swimmers
Barriers inhibiting people from adopting aquatic activities include, but are not limited to:

• Accessibility to pools and swim lessons
• Cultural issues like not wanting /not choosing to learn to swim or participate in aquatic recreation or aquatic sports
• Racial and ethnic factors, including hair care and norms
• Embarrassed to be seen in swimsuits
• Parents who fear water or are unable to swim discouraging children from learning to swim
• Drowning, illness, or injuries that occurred to family and friends
• Negative publicity
• Bad experiences

The Centers for Disease Control and Prevention (CDC) reported that overall, 37 percent of Americans are unable to swim.⁶

Unfortunately, African-Americans (62 percent) and Hispanic-Americans (47 percent) are less likely to know how to swim.⁶

Fear also plays an important role. A study performed by the Gallup organization evaluating 815 subjects indicated that even more people are not confident swimmers since about two-thirds of Americans are afraid of deep, open bodies of water like lakes, rivers, or the ocean and 46 percent are afraid of the deep end of a pool⁷ (Figure 4).

Figure 4.

Drowning
Drowning has a substantial personal, societal, and financial impact.8 Although drowning rates have decreased over the last 15 years, drowning remains the second leading cause of

unintentional injury and death in children ages 1 to 19 years, accounting for about 1,100 child deaths per year.9 Drowning rates are shockingly high among African-American adults, of whom about 62 percent are unable to swim. African-American children between 5-19 years old are six times more likely to drown in a swimming pool than their peers.10 Formal swimming lessons are

associated with an 88 percent reduction in risk of drowning in 1- to 4-year-old children.11 Clearly, swimming competence would also prevent drowning in older age groups.

Financial consequences of drowning
It is impossible to quantify the sociological impact that drowning has had over generations. Lifetime medical costs for unintentional drowning deaths in 2005 in the US totaled almost $13 million. Lifetime medical costs for non-fatal drowning in 2005 reached more than $82 million. If indirect costs such as lifetime productivity losses are included, the fatal and nonfatal costs to society top $4.6 billion and $0.6 billion, respectively. This totals more than $5.3 billion in direct and indirect costs from fatal and nonfatal drowning that occurs in a single year.^{If this number is consistent each year, the financial impact of drowning is about $100 billion for the past 20 years (Figure 5).}

Figure 5.

Drowning
Drowning has a substantial personal, societal, and financial impact.⁸ Although drowning rates have decreased over the last 15 years, drowning remains the second leading cause of unintentional injury and death in children ages 1 to 19 years, accounting for about 1,100 child deaths per year.⁹ Drowning rates are shockingly high among African-American adults, of whom about 62 percent are unable to swim. African-American children between 5-19 years old are six times more likely to drown in a swimming pool than their peers.¹⁰ Formal swimming lessons are associated with an 88 percent reduction in risk of drowning in 1- to 4-year-old children.¹¹ Clearly, swimming competence would also prevent drowning in older age groups.

Financial consequences of drowning
It is impossible to quantify the sociological impact that drowning has had over generations. Lifetime medical costs for unintentional drowning deaths in 2005 in the US totaled almost $13 million. Lifetime medical costs for non-fatal drowning in 2005 reached more than $82 million. If indirect costs such as lifetime productivity losses are included, the fatal and nonfatal costs to society top $4.6 billion and $0.6 billion, respectively. This totals more than $5.3 billion in direct and indirect costs from fatal and nonfatal drowning that occurs in a single year.¹² If this number is consistent each year, the financial impact of drowning is about $100 billion for the past 20 years (Figure 5).

Drowning also has a substantial negative economic impact on companies who build, service, operate, and supply products in this field due to liability cost. An informal opinion from a legal expert estimates that a typical drowning lawsuit costs about $200,000 to defend/settle. Also, the negative perceptions influence consumers to spend discretionary dollars in other areas that may not result in physical activity. Learning to swim remains a key defense against drowning in addition to preventing negative sociological and financial consequences.

Opportunities to have more swimmers
Fear, drowning, disease, injuries, and social and cultural forces are substantial influences to discourage aquatic activity. It is also difficult to change people’s habits. However, the National Swimming Pool Foundation believes that getting more people swimming is vital to national health as a way to prevent ongoing harm from drowning and to create economic prosperity among organizations that help encourage a healthier population.

Strong forces support the potential for more people to become swimmers:

• Civilization formed and prospered beside water
• Instinct, curiosity, or fun draw children and adults to water
• Parents hope that children will survive despite their fears
• The growing body of evidence is that swimming prolongs life and provides unique health benefits

Government and industry will invest heavily to encourage and incentivize physical activity to control healthcare costs and societal suffering.

Society’s needs, the benefits of aquatic activity, and the inability of millions to swim has compelled the National Swimming Pool Foundation to invest time, effort, and money to help more people become swimmers. Becoming capable and confident in the water opens the door to healthier bodies and can reverse the catastrophic societal health and financial consequences of inactivity and aging.

Swimming is a desirable activity
The Sporting Goods Manufacturers’ Association partners with five other organizations to ascertain popularity of various activities.¹³ In 2011, they measured the activity that seven age groups ranging from six to 65+ years of age hope or wish to do (aspirational activity). ‘Swimming for fitness’ was in the top three aspirational activities for every age group. In fact, ‘swimming for fitness’ was the leading aspirational activity for the 6-12 and the 65+ age groups. This finding reinforces commonly-accepted beliefs surrounding the popularity of aquatic activities and swimming in particular. A different published survey of African-Americans indicated a strong desire to swim more and intent to visit a pool weekly despite no/low swim ability.¹⁴

Health benefits of aquatic immersion and activity
It is universally accepted that physical activity is good for health and reduces mortality rates.¹⁵ Studies that compare mortality rates between swimmers and other common physical activities are rare. The most compelling published findings are those which compared 40,517 men (20-90 years of age) who completed health examinations from 1971-2003 as part of the Aerobics Center Longitudinal Study administered by the Cooper Institute.¹⁶ After adjustments for age, body mass index, smoking status, alcohol intake, and family history of cardiovascular disease, swimmers had a 50 percent and 49 percent lower all-cause mortality risk than did men who were walkers or runners (Figure 6).

Figure 6.

Hydrostatic pressure from immersion in water forces more blood to the central organs, increasing cardiac stroke volume and cardiac output, which is similar to the effect caused by exercise.¹⁷ Cardiac stretch is a key measure of heart exercise and health. Thus, immersion causes heart exercise (stretch) that decreases with age and increases with water temperature and depth (Figure 7).

Figure 7.

Water activity and immersion is also ideal for many other ailments. Water is an ideal environment for individuals who suffer from diseases like arthritis, diabetes, dementia, and multiple sclerosis and from physical injuries. Water activity is the right solution for the aging and growing population who are less prone to exercise. With minimal risk of injury, they achieve improved heart, kidney, and respiratory functions, greater relaxation, flexibility, and many other benefits.^15,17

Unfortunately, aquatic activity is unlikely if an individual does not feel comfortable in the water and cannot swim.

Conclusion
Physical inactivity continues to rise, causing troubling increases in obesity and healthcare costs. This trend is not likely to change in the near term since child inactivity rates are high and a large number of baby boomers will pass 65 years of age. As government, insurers, and the private sector encourage and incentivize individuals to stay active to improve health and reduce healthcare costs, activity options are limited for sedentary and older populations. Aquatic activity is an ideal option due to buoyance, cardiac benefits, and respiratory benefits. In addition, swimming is a leading ‘aspirational activity.’

Although there are factors that discourage individuals from becoming competent swimmers, there are societal forces that can overcome these factors. Several exceptional organizations are successful in helping people become swimmers. As a result, the National Swimming Pool Foundation adopts and advocates the following position.

The position
Pool, spa, and aquatic businesses, associations, health-focused organizations, and government must commit to supporting organizations that teach people to swim. More swimmers will result in a healthier society, fewer drownings, and reduced healthcare costs, with more people engaged in a healthy spectrum of aquatic activities.

Acknowledgement
The National Swimming Pool Foundation would like to acknowledge the broad spectrum of ‘innovators’ who participated in the Step Into Swim™ Innovator Meeting on April 25, 2012 in Colorado Springs, CO. Drs. Joan Dorn and Rita Noonan for helping communicate and understand the key issues associated with physical activity and drowning. Byron Embry and Carolyn Betts for helping us feel the importance of these issues. Margaret Smith and Laurie Batter for their assistance in formatting and editing this report. The National Swimming Pool Foundation Board of Directors for their philanthropic spirit and strategic leadership.

Attachment 1
Implementation of the position
Society is fortunate that there are many exceptional learn-to swim programs that train millions of people every year. Rather than create more of these programs, the National Swimming Pool Foundation has initiated the Step into Swim campaign, a ten-year effort to encourage both the private and public sector to sponsor and support existing and exceptional programs that help people take the important step to become swimmers. The goal of the Step Into Swim campaign is to “empower organizations who create more swimmers.”

The National Swimming Pool Foundation will continue to invest in research to demonstrate aquatic health benefits, to pursue policies to establish expectations that every person should be able to swim, and to educate people who care for pools and spas to minimize the risk to those who do enter the water. The new Step Into Swim campaign places greater emphasis on helping more individuals benefit from aquatic activity and reduce the risk of drowning.

Step into Swim Congress
When: Wednesday, October 10, 2012, 1:00–5:00 p.m.
Where: Nauticus Museum, Beside the Battleship Wisconsin, Norfolk, VA. Guests are welcome to attend the Opening Reception of the World Aquatic Health™ Conference from 7:00–8:30 p.m. at the Norfolk Waterside Marriott Hotel.

Since the Step into Swim Congress will kick off the ten year campaign, the Nauticus Museum is a fitting symbol since it signifies ‘The Greatest Generation’ who showed commitment to create a brighter, long-term future. It is time to build this generation’s reputation and vision to create a brighter, long-term future.

Existing learn-to-swim providers will present proposals to expand their ability to teach even more people to become swimmers. The featured organizations will focus on swim programs for 1) children, 2) fearful adults, and 3) minority populations.

By spotlighting and empowering successful programs, the number of swimmers will be increased. Existing learn-to-swim providers already have expertise to attract and teach the target audiences. They have also demonstrated the ability to manage sustainable programs. Thus, the funding provided will help existing programs grow and become more sustainable.

We invite others to join us to help these organizations thrive. The result will be improved public health, reduced drowning, and increased demand for pools, spas, and the associated products.

Call to action
Stakeholders in the pool, spa, aquatics, and health fields are urged to attend the 2012 Step into Swim Congress and sponsor/support/donate to a compelling program. The National Swimming Pool Foundation will work with providers to have programs documented and information available to help sponsors choose the program that best fits their needs. The Foundation asks potential contributors to provide feedback if the programs, organizations, or benefits are not compelling so efforts can be refined.

The goal is to help mankind’s health and to reduce drowning. A tangential benefit will be economic stimulus to a sector focused on improving public health through aquatic activity.

References

1. US Department of Health & Human Services. Physical Activity Guidelines for Americans, http://www.health.gov/paguidelines/guidelines/default.aspx
2. www.health.gov/paguidelines/guidelines/summary.aspx
3. Finkelstein, E.A.; Trogdon, J.G.; Cohen, J.W. and Dietz, W. Annual Medical Spending Attributable to Obesity: Payer-and Service-Specific Estimates. Health Affairs 28(5), 2009: 2822-2831.
4. Finkelstein, E.A.; Khavjoe, O.A.; Thompson, H, et al. Obesity and Severe Obesity Forecasts Through 2030. Am. J. Preventative Med. 42(6), 1-8, 2012
5. Moriarty, J.P.; Brand, M.E.; Olsen, K.D.; Shah, N.D.; Borah, B.J.; Wagie, A.E.; Eggington, J.S. and Naessens, J.M. The Effect of Incremental Costs of Smoking and Obesity on Health Care Costs Among Adults, A 7-Year Longitudinal Study, JOWM 54(3); 2012: 286-291.
6. Gilchrist, J.; Sacks, J.J. and Branche, C.M. Self-Reporting Swimming Ability in US Adults. Public Health Reports 2000; 115(2): 110-1.
7. Dash, M. Fearful Swimmers, World Aquatic Health Conference, 2008.
8. WISQARS Cost of Injury Module. http://wisqars.cdc.gov:8080/cost/
9. Bowman, S.M.; Aitken, M.E.; Robbins, J.M. and Baker, S.P. Trends in US Pediatric Drowning Hospitalizations 1993-2008. Pediatrics 129(2): 275-281.
10. Centers for Disease Control and Prevention, Stay Safe in and Around Swimming Pools. http://www.cdc.gov/Features/dsSafeSwimmingPool/
11. Brenner, R.A.; Taneja, G.S.; Haynie, D.L. et al. Association Between Swimming Lessons and Drowning in Childhood, Arch. Pediat. Adolesc. Med. 163(3): 203-210
12. Finklestein, E.A.; Corso, P.S.; Miller, T.R. The Incidence and Economic Burden of Injuries in the United States. Oxford University Press. 2006
13. Sporting Goods Manufacturer’s Association, State of the Industry 2011, The Sport and Fitness Products Industry Rebounds, p. 28.
14. Irwin, C.; Irwin, R.; Martin, N. 7 Rossl. Presented to USA Swimming, Constraints Impacting Minority Swimming Participation, Phase II.
15. Centers for Disease Control and Prevention. Physical Activity Guidelines for Americans. http://www.health.gov/paguidelines/Report/Default.aspx
16. Chase, N; Sui, X. and Blair, S.N. Swimming and All—Cause Mortality Risk Compared with Running, Walking, and Sedentary Habits in Men. Int. J. Aqu. Res. & Ed. 2008, 2(3), 213-223
17. Becker, B.E. Editor. Comprehensive Aquatic Therapy, 3rd Edition, Chapter 2, Biophysiological Aspects of Hydrotherapy, WSU Publishing. 2011. Tajima, J. Am. J. Physiology. 1988, 254 (6 Pt 2): R977-R983.

About the author
Thomas M. Lachocki, PhD, is CEO of the National Swimming Pool Foundation (NSPF). He earned his PhD in chemistry from Louisiana State University and his BS from Lock Haven University, PA. Lachocki has researched and published in diverse fields, including catalysts, detergents, solvents and recreational water. He was awarded six patents that have been issued and are practiced in at least eight countries. Contact him at (719) 540-9119; (719) 540-2787 (fax) or [email protected]; for complete information about NSPF and its programs, visit www.nspf.org.