Health promotion focus on bad habits criticized.

SAN DIEGO -- Physicians should be prescribing pleasure instead of haranguing people so much about their bad habits, Dr. David Sobel said at a meeting on alternative medicine sponsored by the American Hospital Association.

The medical establishment puts most of its health promotion energy into educating the public about health risk factors and how to avoid them, but much disease is not explained by traditional risk factors, said Dr. Sobel, who is director of patient education and health promotion for Kaiser Permanente Northern California in Oakland.

At the same time, much evidence shows that joys can be healthy, and it makes sense to assume the species evolved with instincts for that which is healthy. Most dangerous behaviors, such as smoking tobacco, tend to be recent developments, in an evolutionary sense, he said.

This aspect of health is relatively underutilized in health care, Dr. Sobel said.

"We usually think we can scare people into good health, and, in a sense, we have become medical terrorists and health fascists," he said.

Dr. Sobel discussed some of the following ways that pleasure can be heart healthy:

* Happiness. Depression in cardiac patients is a greater predictor of a future cardiovascular event than smoking or high cholesterol. Anhedonia is the key feature of depression, Dr. Sobel said, so he often uses it to screen for depression. He asks: What is the one thing that you really enjoy doing? When a patient cannot answer, he suspects depression.

* Marital satisfaction. A divorce carries as much cardiovascular risk as smoking one pack of cigarettes a day.

* Naps. A Greek study said that men who napped had a 30%-50% reduced risk of heart attack. Those naps should not be too long, however, Dr. Sobel said. The study showed a dose-response curve, and naps longer than 1 hour were not healthy.

* Vacations. Regular, annual vacations have been associated with a 30% reduction in cardiovascular risk.

* Sex. According to one 1997 study of five Welsh villages, men who had the most orgasms (twice a week or more) had 50% lower mortality than those who had the least, and there appeared to be a dose response. "This was after controlling for age, social class, smoking, blood pressure, and health status at the outset," Dr. Sobel said.

* Humor. One study of patients recovering from heart attack found that those who were directed to watch a humorous video for 30 minutes every day had fewer arrhythmias, lower blood pressure, and one-fifth the rate of a second heart attack, compared with controls.

"I wouldn't go to the bank on this one--it was a small study," Dr. Sobel said. "On the other hand, most of our cardiac rehabilitation does not prescribe humor, which would be easy enough."

* Pets. Pet owners have been shown to have one-fifth the rate of second heart attack relative to those without pets. The type of pet does not seem to matter, Dr. Sobel said.

* Alcohol. Much evidence suggests that one or two drinks a day can reduce coronary artery disease risk by 33%. Dr. Sobel said he has a hard time recommending this one to patients, however, since daily use and moderation are the key.

* Relaxation. Men who were able to say that they could leave their work at work when they came home had one-third the cardiac risk of other men.

Other things related to pleasure that have been shown to affect health and disease recovery, though not specifically cardiovascular disease, include touch, a positive outlook, altruism, and the ability to get outside one's self and condition.

There was even a study of medical students shown a video of Mother Teresa helping the poor, and while the students expressed discomfort at having to watch the scenes of squalor and suffering, it was found that their salivary IgA levels rose.

"At a physiological level, even seeing a selfless act of connection actually has an effect and speaks to our physiology," he said.

This evidence raises the question, Dr. Sobel said: "Is this the type of training and support that we give in terms of reducing cardiac risk? Are we including, as a compliment to the care we provide, some things that help people realize what is really important to them?"

BY TIMOTHY F. KIRN

Sacramento Bureau