What does it mean to be healthy?

Myself, the fitness community, and the world at large talk about health a lot.

“This can improve your health”

“This isn’t ideal for your health”

“Doing this has been associated with better/worse health outcomes”

…and so on.

But here's the thing:

When we speak or write about any given topic, we can sometimes use a word and just assume people know what we mean. If I say 'dog', I do so as shorthand for 'Canis lupus familiaris, the four-legged domesticated animal...etc, etc, etc' and I just make the assumption that you do the same thing when you hear it. I assume that you and I both have the same working definition of the word ‘dog’. Not doing this and instead spending ages outlining the specific meaning of every word we use during typical conversations would make chatting about even simple topics take ages, and so that’s not how language tends to work.

In order to avoid this, we all basically assume that the words we use mean the same thing to us as they do to our audience, and usually this is fine, but here we presuppose that everyone has the same working definitions within the same contexts and sometimes that may not be the case.

For example, if I say I need a new chair for my office I might assume that because it’s an office you would infer that I mean one of those spinny chairs with wheels that people sit on to work at computers most of the time. But what guarantee do I have that you use that word in the same way as I do, given the same context? What if you’ve always had an armchair in your office, would you assume that’s what I mean?

Language can be complicated like that, and so if I wanted to send you to a shop to buy the chair I wanted, I wouldn’t just say I needed a chair, I’d describe exactly what I mean because if we just use single words and provide no background then people can misunderstand us. Not all the time – most of the time we don’t need to bother because we all have similar understandings of the same words.

But sometimes this is an incorrect assumption. What I want to tell you today is that this is almost certainly the case when we talk about health, because it's not actually clear what health is. It’s not that some people understand what health is and some people are wrong about it. It’s that health doesn’t really have a single coherent definition meaning that people can often fall into the trap of talking past each other, and also that people can develop a confused image in their mind about their – and other people’s – overall wellbeing.

In the rest of this blog, I want to point out why it's actually really hard to define health, and then tell you why this is actually really, really important for health and fitness professionals, and for everyone else who's just interested in being as healthy as they can be.

Let’s get in to it.

The World Health Organisation – They should know this, right?

Health has been defined by the World Health Organisation as a complete state of mental, social, and physical wellbeing, not just the absence of illness or infirmity, which was at the time an upgrade on the previous definition which was basically "not currently sick or injured".

But as we note in one of the first modules on The BTN Academy, there are some problems with this definition.

• Who defines what a complete state is?
• How do you know when you get there?
• What if you can NEVER get there - for example if you're born with a condition like Spina Bifida does that mean you are ALWAYS just an unhealthy person because you don't have what most would consider to be a complete state of physical wellbeing?

And even more importantly:

• What if a move away from a complete state is, itself, healthy? For example, if a beloved family pet passes away then this will leave you in something that could hardly be defined as a complete state of mental wellbeing, but that's because you're grieving...which is healthy

And so, a more up-to-date definition has been suggested: a slightly more vague idea that amounts to "able to adapt to your current environment and react accordingly in order to return to baseline" which just basically means that if something goes bad then you're able to deal with it properly and get back to where you should be.

But again, what is baseline? Where should you be? Who gets to decide that and upon what criteria are they basing their decision?

If someone loses an arm, the wound can heal, and your body can return to normal in a biochemical sense so is that person healthy despite not being where they were prior to the injury? I mean, if ‘able to return to baseline’ is healthy none of us are really healthy because we can’t regenerate a limb.

If a person is under extreme stress at work and at home, they are likely to be less able to deal with a bereavement in a healthy manner, but are we really correct in saying that this person is unhealthy? Is it not the case that they are a healthy person in a bad situation?

On that topic, if we lose a very close loved one, that can affect us for life. Does that make a widow/widower unhealthy forever? Who gets to decide?

See, it's complicated.

Is health relative?

It’s complicated because what health is, is more relative than is immediately obvious.

The philosopher Richard Boyd uses this as an example when he outlines his “Homeostatic Cluster Property Theory of Meta-ethical Naturalism" which is some ethical thing that's really complicated, and if I’m being honest I barely understand it, but that doesn't matter for our purposes today.

(Philosophy students don't @ me)

What matters is his use of health as an example, which is really interesting and important in a world that is growing more and more interested in promoting health, but also a world in which movements such as healthy at any size, the anti-diet movement, and other medical/ethical/mental health related conversations are coming to the foreground.

The Philosophy of Health

Here's the proposal:

"Health" is a real thing that actually exists. It is possible to be healthy, it is possible to be not healthy, and so on. The designation of good or ill health is not arbitrary.

But, rather than being a discrete category, "Health" is a cluster of things that often go together and that we often intuit rather than properly explain. You can look at/talk to a person and tell me whether they're healthy or not, and you’ll be able to say why, but you will not be able to explain health holistically in the abstract. The reason is demonstrated below.

If I asked you to do me a list of all the things that define health, you may come up with something like:

Breathing
Free of cuts, burns, and other wounds
Free of disease
Heart is beating
Has friends
Free of anxiety
Etc.

But these things are just properties that correlate with health and with each other, rather than things that are NECESSARILY present in all cases of good health or absent in cases of bad health.

For example, if a person burns themselves on the stove but were otherwise fine, few would call them unhealthy despite the fact that they have the burn – they’re just a healthy person with a burn. If you have a bit of a sniffle, you'd probably describe yourself as healthy despite the fact that objectively you have some kind of disease/bug/illness.

And moreover, it is possible to find a breathing, disease-free person who has no wounds and a beating heart that we would describe as unhealthy for other reasons - maybe they have a drug addiction?

Follow this rabbit hole long enough and you start to come up against some really tough-to-answer questions.

• Is a smoker who doesn’t have any current lung/mouth/throat problems healthy?
• What about a person with plantar fasciitis?
• Is a person with osteoarthritis more or less healthy than a person with gingivitis?
• Is a person with obesity, but no other health issues, healthy?

The answers are pretty much down to how you define it all, aren’t they? Which things do you find most important? How important are they relative to other things? And so on.

You can probably answer those questions to a point, but someone else would answer them differently and there's no way of knowing objectively who's more right because there is no single definition of health that would describe the condition of every healthy person but exclude every unhealthy person, and there is no sliding scale that allows fair comparisons between two people unless you already defined the thing you’re looking at (meaning you can’t say whether Dave is healthier than Steve unless you come up with a means of comparison like blood pressure, glucose tolerance, etc).

A personal definition of health

The definition of a healthy person is therefore "A person that has all of the clustered properties that I would put under the heading of health, and that I personally find valuable, and who doesn't have sufficient problems in any of the areas that I personally care about, for me, personally, to consider it bad enough to define them as not healthy anymore".

The issue is that this definition, while being the only definition that actually makes sense, is extremely individual and open to opinion and bias, and it also changes context to context.

A person who is healthy but has very pale skin may not be able to adapt well to their environment if you placed them in a really hot country without sunscreen, but while sat at home in Arbroath they’re perfectly healthy.

And so, your understanding of what health means is informed by your biases, your opinions, your preferences, and the context in which you find yourself.

And the same goes for me and everybody else, too.

This means that in order to define health you have to make judgement calls. Which of the properties that can go under the heading "health" do you find important? How important is each relative to the others? How far away from ideal can a person move, in any of the clustered things, for it to become a problem?

You can answer some of that with data, but even then, the interpretation of the data requires a judgement call. If your blood pressure is elevated so that statistically you are 1% more likely to have a heart attack than you would be if your BP was perfect, are you unhealthy?

What about 2%?

Where's the cut off in your opinion, or the opinion of any given physician, and why is it there rather than somewhere else?

You can say, relatively speaking, that a person who’s blood triglycerides leave them as being statistically 7% more likely to have a heart attack is less healthy than someone at 6% greater risk, but what if the 7% person has 1% more risk of diabetes than the 6% person does?

Does this bring them back to baseline again, or does one matter more than the other, and why?

Does that 1% elevated risk between them even matter or are they just a healthy/unhealthy as each other despite the small statistical difference?

Complicated, isn't it?

And that's why it's important.

Because there is no definition of health that doesn't include a value judgement, there is no definition of a healthy person that is objective (outside of a mythical being who has literally no physical, mental, social, spiritual or career problems at all in their life ever). It always has some personal interpretation and bias.

And that personal interpretation and bias then alters how we treat the person in question. It affects how we treat ourselves.

Now don’t get me wrong, in many cases we all agree on the same terms and so the course of action. For example a person with breast cancer is unhealthy and needs treatment. A person with profuse bleeding is unhealthy and needs to have that wound sorted out ASAP.

But what about a person with binge eating disorder who is of a “normal weight”? Are they unhealthy? Do they need treatment? What kind of treatment do they need? What is the ideal outcome?

Would you change your answer to the above if the person was overweight?

How overweight would they need to be, and why is the bar there?

Who’s more unhealthy and in need of dietary intervention, an active person with obesity but who has a great relationship with food and their body, or an extremely athletic person with orthorexia nervosa and body dysmorphia?

If we’re honest with ourselves we’re not really able to answer these questions objectively, but that doesn’t stop us making these judgement calls intuitively when we see people. We judge a person, and this affects how we treat them, but can’t justify it using objective reasoning, and that is *not* a good thing.

Is a person with obesity unhealthy per se? If so why, and on what other factors would that judgement depend?

Can you say, without any subjectivity, whether or not a person who goes to the gym because they are dissatisfied with their body is healthy?

I would argue that you can't answer any of those with complete objectivity. It always depends, and even what things it depends on…depends.

So…can you be healthy at any size?

In the person with obesity example above, do you consider a larger amount of bodyfat on its own to be a loss of health? Or does that depend on glucose tolerance? If it does, how much does it depend on that, how much of a change is needed for it to break the barrier of 'not healthy' and why? What else does it depend on, and why?

Now the above paragraphs sound kinda accusatory – lots of rhetorical questions that you may not be able to answer, but I’m not trying to point a finger here. I’ve written this as neutrally as I can while still making the point I want to make.

Instead, I’m just asking you to think really critically about how you think about health, and why you think that way, whether in other people or in yourself.

What is the perception you have around what health is, how solid is that perception or how shaky is the ground on which it’s stood, and then how much do you base your actions and thoughts around this potentially very shaky definition of a word that means an awful lot to all of us?

Do you consider yourself to be unhealthy? Or healthy? How do you judge the health of others?

Why is that, and what are you paying the most attention to there? Are you defining yourself or someone else as healthy or unhealthy based on your own understanding of the terms, or have you just accepted a definition that you have heard repeated often but without justification?

If you do consider yourself to be unhealthy, what would really need to change for you to become healthy again? The same question goes for your clients.

This is all lofty and abstract, but it really matters and to show that and close this blog I’m going to get specific.

If we are in the business of helping people improve their health, we really need to come to terms with the subjective nature of the word. We really need to understand why so many highly educated people talk about the idea of being healthy despite being significantly overweight. We need to think about the psychological effects that repeated dieting efforts can have. We also need to be really cognisant of the beneficial physical and psychological effects of dieting that some people get.

Remember, intentional weight loss is not neutral, it can help or it can hurt, so which is going to happen in any given situation?

Who’s healthier:

1. Jane, 250lbs, active in a way she enjoys, eating lots of fruit and vegetables, confident
2. Jane, 180lbs after 70lbs of weight loss, overexerciser, occasional binge eater, terrified of regaining weight

What we’d all likely agree is ‘the best’ outcome would be the weight from point 2 with the rest from point 1, but we all know that things don’t always work out that way and so in conversations around weight loss we need to avoid pretending that it is. And as a coach we need to really know this so that we don’t just help people lose weight but rather help them improve their health holistically – and sometimes we need to remember that this may mean no intentional weight loss at all.

But then of course sometimes it might. While it's very true that Jane may develop some harmful thoughts about her body image and a bad food relationship during this process we should not ignore the countless examples of people who diet and find the process psychologically empowering while also improving cardiovascular health, glucose tolerance, and so on.

In short, we need to know what health really means to us or the person in front of us and then we need to act according to both that definition and also the real-world effects of what we do.

Is losing weight really going to improve the health of this person?

Conversely, is avoiding the process of dieting really the best thing for them or would they actually benefit from that journey?

Is tracking calories/macros helping or hurting the health of the person I’m talking to?

Really give it some pondering. The answer isn’t as straightforward as we sometimes like to think.