The Tribune, Chandigarh, India

The meaning of health
By Dr Robert M. Youngson

The Greeks did not consider health to be a single entity and used two separate words heuexia, meaning “a good habit of body”, and hygieia, meaning “a good way of living”. They were also alive to the importance of the distinction between mind and body in this context. In the Platonic dialogue Charmides, Socrates argued that a physician who tried to heal the body without also healing the mind was a fool. One should, he said, attend first to the state of the mind, for health was dependent on virtue. Being well in body required that we should establish good habits of living.

The World health organisation’s (WHO) official definition of health reads: “Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease and infirmity.” It is not at all easy to quantify health in this positive sense, however, and, for practical purposes, health professionals, especially community physicians and statisticians, must rely on negative indices — such as mortality rates and illness and disability figures — in trying to assess the health of a community.

From the individual point of view, however, some rough measure of quantification is possible. Health implies “fitness” — the ability to perform and to live a full life. Large numbers of people are free from organic disease but are so unfit that only the most sedentary of lifestyles is possible for them, and such people cannot be considered healthy. Positive health is usually associated with a feeling of wellbeing and is almost always the result of high motivation for living. There is an important relationship between lack of fitness and ill health; ultimately the kind of lifestyle that results in unfitness is apt also to be the kind that leads to actual disease. Factors that adversely affect a person’s fitness levels include physical idleness, an unsuitable diet, overeating, drinking too much alcohol, and smoking.

Fitness

Fitness is essentially a matter of the amount of exercise an individual can tolerate. The concept of exercise tolerance is important as this allows useful comparisons of the state of fitness to be made. It is also important as a way of assessing heart and respiratory-system disease. The exercise tolerance scale is a kind of fitness hierarchy with long-distance athletes at the top and bed-ridden cardiac patients at the bottom. The scale may be calibrated in terms of the distance that can be travelled, at a brisk pace, before the person has to stop because of severe breathlessness, or other effects. Most people are somewhere near the bottom of the scale.

People who are unfit but free from disease can, whatever their age, readily increase their tolerance by taking regular exercise. Even people with a heart or respiratory condition can often also do so, but close medical supervision is necessary. In the investigation of such cases doctors will always try to assess the exercise tolerance. A patient with angina pectoris (a condition in which the coronary arteries are unable adequately to supply the heart with blood) may be able to walk 50 m before being stopped by pain. Later, if the condition gets worse, he or she may be able to go only 20 m before the symptom occurs. Fit people can easily run up several flights of stairs, two or three steps at a time, while those who are less fit can only walk, one step at a time. Some instinctively avoid stairs, finding that even talking is difficult while climbing them, because of breathlessness.

Breathlessness and a fast pulse rate are the normal response to exertion. Their degree, however, for a given amount of exertion, varies widely between people of different standards of fitness. This is because of the many physiological and even structural changes that occur in the heart, lungs and muscles as a result of training. Because of their higher cardio-respiratory efficiency, athletes usually have slow resting pulse rates, and a long-distance runner may have a resting pulse rate of as low as 40 beats per minute. Above a certain heart rate, pumping efficiency drops, so if a heart can work efficiently up to 160 beats per minute (which is normal) an unfit person will only be able to exert it to the point where it is working at twice its rate when resting, without being stressed, while an athlete can quadruple its rate. Circulatory efficiency is not, however, simply a matter of heart rate. The important parameter is cardiac output the amount of blood that can be pumped in a given time. This is the product of heart rate and stroke volume (the volume pumped per contraction). Stroke volume varies with the power and efficiency of the contraction of the heart muscle with each beat. In a trained athlete, the heart output may rise from the resting value of 5 litres (approximately 9 pt) per minute, to a level as high as 35 (62)

How to assess fitness

The degree of breathlessness on effort is a sensitive index of the degree of fitness. Men or women well into middle age, who are not particularly concerned with athletic pursuits, should still be able to do the following:

*Walk ten miles.

*Walk at a brisk pace for a mile without embarrassing breathlessness.

*Continue after this, at a more normal pace, without difficulty.

*Run up a flight of 20 steps in seven bounds with no overt sign of distress.

*In an emergency, run 30 m (about 33 yd) in under seven seconds.

The significance of symptoms

The list of possible symptoms is very long, but there is a small group of commonly occurring ones that may cause particular concern. Some idea of the possible significance of these factors may have a bearing on the assessment of the state of an individual’s health.

Breathlessness: Apart from simple unfitness breathlessness has many possible causes. A sudden chance in the degree of breathlessness for a given amount of exertion, or breathlessness at rest, are always significant and require investigation. Other causes include: smoking, an over-full stomach, well-advanced pregnancy, obesity, anaemia, general debility, heart disorder, pneumonia or other respiratory infections, emphysema (break-down of the lung sacs so that a smaller area is available for oxygen transfer), asthma, spontaneous pneumothorax (local rupture of the lung covering so that air escapes from the lung and collapses it), and obstruction of the larynx or trachea (windpipe).

Chest pain. The chief concern with this symptom is that it may signify heart disease. This is essentially a male problem because women are protected by their sex hormones until after the menopause and enjoy a high degree of immunity to coronary artery disease. Most chest pains have an innocent explanation, however, and pain that is constantly, or frequently present, unrelated to exertion, emotion or stress, and that in no way interferes with activity, is unlikely to be due to a heart problem.

Common causes of chest pain include ‘‘heartburn’’ (reflux oesophagitis in which acid wells up into the gullet from the stomach), spasm of the oesophagus, ‘‘wind’’ from air swallowing in attempts to belch, hunger, part of the stomach pushing up through the diaphragm (hiatus hernia), inflammation of the lung coverings (pleurisy), inflammation of the heart’s outer capsule (pericarditis), a virus infection causing pain in the chest muscle (Bornholm’s epidemic myalgia), pain in the nerves supplying the respiratory muscles between the ribs (intercostal neuritis), disease of the joints between the ribs and the breastbone, bronchitis or tracheitis, bulging (aneurysm) of the aorta, and cancer of the lung. This list is by no means exhaustive.

In the case of angina pectoris, the pain begins beyond a certain degree of exertion, and on resting it is quickly relieved. It is usually felt just behind the breastbone and may be very severe or no more than a vague ache. A pain of this kind that is not quickly relieved by rest may be due to a heart attack.

Headache: Headache is so common and brain tumours so rare that the chances of a particular headache being caused by a tumour are very small, and, in fact, three quarters of all headaches are caused by muscle tension. Of the remainder most are migraines (headaches due to changes in the arteries supplying the scalp and brain) and these usually involve visual disturbances. The third, very minor group contains many different organic conditions that can cause headache. Headaches in this group are nearly always associated with other, often severe, symptoms. For instance, brain tumours commonly cause loss of peripheral vision, double vision, sudden projectile vomiting, weakness, loss of sensation, speech difficulties, and so on.

Other symptoms and signs. New, persistent or frequently recurring pain in any part of the body should be medically investigated. Other areas of concern include: an unexplained and persistent cough, coughing up or vomiting of blood, blood in the urine or in the stools tarry black or stringy stools, any unusual or unexplained change in the bowel habit, urinary incontinence, burning pain on urination, undue frequency of urination with small output, or excessive urinary output with constant thirst. Any of these might indicate a serious problem and should be examined medically.

(Courtesy Dr Christine Winters and Dr Stephen Adamsom)

Environment and you

Humans are highly adaptable and able to live in many different types of climate. However, some regions are better for your health than others. You cannot alter the overall climate but, if you are aware of the potential risks in your own environment, you can control existing health problems and reduce the risks to your health.

The air you breathe: Avoid living at high altitude if you suffer from a respiratory disorder such as emphysema. The lower oxygen content in the air will make your condition worse.

Air pollution from car exhaust fumes and industrial pollution, at any altitude, is not good for your health, especially if you suffer from bronchitis or asthma. people with breathing difficulties should also try to avoid situations where they will be exposed to tobacco smoke.

The water you drink:Some studies show that people who live in soft water areas have a slightly higher incidence of heart disease, and a higher death rate, than people in hard water areas. The differences are too small to warrant moving from a soft to a hard water area but artificially softening water is not recommended.

If you are concerned about the purity of your drinking water you can switch to bottled mineral water or start to filter your tap water. Both these methods can, however, cause health problems if they are used incorrectly; bottled water that has been opened should be stored in the refrigerator to reduce the risk of bacterial contamination and the tap-water filter must be changed regularly. Positive steps that will improve your water include replacing old lead-lined water tanks and pipes in your house and using fresh mains water whenever you boil the kettle.

The food you eat: Fertilisers, pesticides, additives, and preservatives, that are used in the production of our food, are claimed by some people to cause cancer, allergies, and occasionally, hyperactivity in children.

The risk from chemicals in food are, however, far less important than those of an unhealthy diet containing too much fat, and those of alcohol and tobacco. People who buy only organic foods should check them carefully to be sure that they are in good condition since they have not been treated with preservatives. Because spoiled food is a serious health risk, preservatives are added to foods to stop them from becoming mouldy.

Too much sunlight: Although many people worry about the harmful effects of radiation from nuclear power stations, the risks for most of the population are extremely small. In actual fact, there is a far greater threat to your health from the large doses of ultraviolet radiation that you absorb through lying in the sun for long periods of time. Therefore, if you sunbathe less, and avoid all unnecessary medical x-rays, you will help to keep your exposure to radiation within safe limits.

A little sunlight is needed every day to promote the production of vitamin D in the skin. However, too much exposure to then sun or to the ultraviolet rays of a sun lamp will prematurely age your skin. If you are very fair-skinned, it will also increase your chance of developing skin cancer. Children who suffer from recurrent sunburn are also more likely to develop skin cancer later in life.

Background radiation: People who work directly with sources of radiation have to take the most stringent safeguards to protect themselves. But there is probably nothing you can do to reduce the very small risk of developing cancer due to the low level of natural ionizing radiation that is present in the environment.

This background radiation comes from two main sources: cosmic rays from outer space and radon gas emanating mainly from uranium ores in the earth's crust. The level of natural radiation usually falls well within defined safety limits. However, in some cases, particularly where there is mainly granite rock beneath the soil, a higher than average amount of radon gas maybe detected. If you live in a high-risk area, you can have the level of radon measured in your house. If there is a build-up of the gas, all you need to do to make your home environment safe again is to improve the ventilation.

Environmental allergies: Hay fever and also some asthmas and eczemas are caused by allergic reactions to substances in your environment. If you are sensitive to pollen you should monitor the pollen count and try to avoid going outdoors on high count days. Fitting indoor air filters and keeping your windows and doors shut will also help. A dust allergy can be eased by frequent vacuum cleaning and by using a spray every few months to eradicate house-dust mites from your bedding and soft furnishings.

— By Drs Stephen Carroll and Tony Smith