The Picture of Health

By: Nick Soleyn, PBC, Editor in Chief

Health, like fitness, is a meandering concept, depending on your stage in life and what it is that you value most. When you sit across from your doctor, your doctor is composing a snapshot of your health, based on what the doctor can observe. Each observation is a piece of the picture of your overall health, signals that, when taken as a whole, give some insight into your statistical longevity. Raising the questions, “What is most likely to kill you? And how soon?” The backdrop against which the doctor might view the picture of your health is whatever research and experience suggest about someone who has the same collection of observations that you do—someone your age and gender, size and shape, with your familial and medical histories, and your health markers.

The problem is the snapshot aspect of the question, “Are you healthy?” as there is no agreed-upon backdrop as to what a standard of health looks like. If we were biomechanical machines, we could assume that positive health markers lead to longevity. Yet, a person can be fit as a fiddle, while still being weak, lacking muscle mass and ill-prepared if some disease or accident relegates them to bed for an extended period of time. Others will cultivate health as a dynamic force, something that must be constantly maintained through a “healthy lifestyle.” But even that carries assumptions that we know what “healthy” means. For most people, we can assume that being healthy is some combination of being fit and functional for the tasks of their daily lives and being as physically insured against disease, disability, or disorders as possible.

Life is like gambling. Until the cards are revealed, the best you can do is play the odds and put statistics in your favor. There is no guarantee against the surprise heart attack, the cancer diagnosis, the freak accident. The only certainty is that something is going to eventually catch up to you. Most of us prefer that it happens in our old age when we’ve seen our loved ones cared for, just after we’re done kicking butt, and just before serious decline sets in. Until then, when we pursue health, we are trying to maximize our statistical longevity.

Health and longevity seem to find a meeting place in functional assessments. Maintaining self-care, independence, and the ability to live and thrive in the presence of aging, disease, or disability is grounds for a positive, healthy outcome when life’s slings and arrows inevitably catch you. Their opposites tend to signal a declining quality of life, frailty, and the expectation of poor health markers.

Function Over Form

Function has been a consistent proxy for health, recovery, and progress or decline in the clinical setting for some time. In the 1960s and ’70s, researchers sought to create a standard measurement for elderly patients suffering from strokes, hip fractures, and other disabling conditionings as the basis of making prognoses and identifying progress toward independence. Physical improvements consistently predicted a return to independence. Physical deterioration or decline, such as the loss of the ability to bathe oneself or walk unassisted, consistently heralded poor prognoses.

The order of recovery or decline occurred on a scale of functions: dressing and bathing, eating, ambulating, toileting or continence control, and hygiene. These functions eventually made up the Activities of Daily Living (ADL) index, pioneered by Dr. Sidney Katz in his work in geriatric care. Early researchers noted that the order in which patients who lose or regain functions on the ADL index mirrored the development of primary functions of children. Early losses were to more complex tasks like bathing and hygiene, and final stage losses involved the ability to feed oneself. The concept of base quality of life comes from the ADL index and some expanded indices that include functional assessments of one’s ability to live independently in a community. (See Linda S. Noelker and Richard Browdie, “Sidney Katz, MD: A New Paradigm for Chronic Illness and Long-Term Care,” The Gerontologist, vol. 54, No. 1 (2013))

Positive outcomes tend to skew in favor of those who are more independent, less frail, and meet the markers of longevity. For non-pathological issues, that usually falls along the spectrum of one’s weight and body composition, diet, and an improvement in clinical health markers like cholesterol and blood pressure. The underlying assumption is that your picture of your health can look better if you just touch up certain areas. People often neglect the most superficial of those areas—physical functionality—despite it being closely associated with aging well.

Frailty

Frailty is the “recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is compromised.” (Xue, 2011) There are different ways to measure frailty, but a phenotypic definition—one based on the interaction with one’s environment—will typically identify a person as frail who meets three out of five of the following criteria:

• Unintentional weight loss
• Exhaustion or low energy
• Low physical activity
• Slowness: a noticeable decrease in walking speed
• Weakness: low grip strength

This phenotypic evaluation of frailty is useful in the clinical setting, where your doctor is taking your measure. It is not comprehensive, but it gives a picture of cause and effect and meets the needs for a statistical assessment of longevity.

Function for Health

Functionality presumes strength. The most basic functional tests of balance and muscle power require adequate levels of strength. Some outcome-based observations—how well you can sit or stand, how many push-ups you can perform, or how much power you can produce—are measurements of some more basic physical capacity.

A lot of functional assessments as we age have to do with the ability to maintain balance. Balance is a state in which your center of mass stays vertically over your base of support. Balance is a trainable skill, improving with practice. And more skeletal muscle mass means better balance as you age. Lifting requires you to control your center of mass at increasingly heavier weights in various challenging positions. As you improve your skill at barbell training, you improve the skill of balance; as you build muscle through training, you also improve the machinery responsible for keeping you upright.

Popular research has identified muscular power as a reliable anti-frailty indicator for aging adults. Muscular power measures the amount of force you can and how quickly. If we accept the assumption that a greater potential to produce power leads to better longevity outcomes, then we must answer the question, “How do we improve our ability to demonstrate muscular power?”

Power is force times distance over time. For a given range of motion, you can demonstrate more power by either producing more force or moving the weight more quickly. A person may improve their mechanical force by increasing the number of contractile fibers in their muscle tissue through basic strength training. Training for strength will improve your ability to produce force—and, therefore, power. Many studies make the inductive leap that because muscle power is important, people should train lift light-weights quickly. While there is nothing wrong with dynamic or “power” training for people that can safely do so, the assumption that you can only build power by lifting quickly is false. (Read more: “Should You Train for Power?”)

Health, ultimately, is a complex issue. There is much more to you than what you can do, how old you are, and who your parents are. Health and the concerns of longevity should be confronted with your doctor. But, as you anticipate sitting on the observation table, being weighed and measured, you are more likely to hear good news if you engage in regular exercise, eat well, and have healthy habits. And, from the looks of many of these types of functional assessments, the picture of health starts with building and maintaining strength.