Comparative-Effectiveness of Population Strategies to Improve Diet and Reduce CVD

摘要 心血管疾病(CVD)是美国和全球主要的死亡原因。在美国，每年心血管疾病的直接和间接成本估计超过5000亿美元。这些负担可能会随着人口老龄化、医疗成本上升、心脏事件后患者存活率的提高以及肥胖和糖尿病等主要心血管危险因素的增加而进一步增加。我们自己和其他许多人的研究表明，不良的饮食习惯是心血管疾病的一个主要可预防的原因。我们之前的工作表明，过量的盐和反式脂肪以及不足的多不饱和脂肪(取代饱和脂肪)、水果和蔬菜以及海鲜omega-3脂肪分别是美国每年数万名心血管疾病死亡的原因。含糖饮料(SSB)和加工肉类的高摄入量以及坚果和全谷物摄入量不足也会增加心血管疾病的风险。显然，改变饮食以改善心血管疾病是一个需要解决的重大挑战。考虑到大多数心血管疾病都为时过早，可以预防或推迟，这个数万亿美元的问题是“哪些干预措施最有效地改善饮食和减少心血管疾病？” 我们建议评估以循证为基础的人群干预措施改善饮食的相对有效性(目标1)。我们将把重点放在人口层面的方法上，因为与个人层面的方法相比，这些方法更可持续，成本更低。我们将根据前期工作的结果选择最有希望的人群干预措施，并根据已发表的证据量化其对饮食的影响大小。我们将主要关注水果和蔬菜、膳食脂肪、盐和SSB的有效大小。根据数据的可得性，我们将次要考虑海鲜omega-3脂肪、坚果、全谷物和加工肉类。我们将利用目标1的结果，随后使用具有全国代表性的数据(目标2)，评估循证人群饮食干预措施在美国按年龄和性别降低心血管疾病死亡率的比较有效性。显然，迫切需要制定一种一致的方法，以比较美国不同人口干预措施对心血管疾病的影响。作为这一努力的一部分，我们将在之前的工作基础上开发和扩展三种不同的模型。 对改善饮食和减少心血管疾病的循证人口战略的相对有效性的评估，以及为执行这种评估而开发的一致方法，都是新颖的，将为美国的循证预防努力提供重要的见解，并为未来的研究确定重要的差距。在美国，应用这一知识将是延长健康寿命和减少巨大且不断增加的心血管疾病负担的当务之急。

Abstract Cardiovascular disease (CVD) is the leading cause of death in the US and globally. In the US, the estimated direct and indirect costs of CVD exceed half a trillion dollars each year. These burdens may increase further with the aging of the population, escalating healthcare costs, improved patient survival following cardiac events, and increasing rates of major CVD risk factors such as obesity and diabetes. Our own work and that of many others has demonstrated that poor dietary habits are a major preventable cause of CVD. Our prior work has shown that excess salt and trans fats and insufficient polyunsaturated fats (in place of saturated fats), fruits and vegetables, and seafood omega-3 fats each account for tens of thousands of CVD deaths in the US each year. High intakes of sugar-sweetened beverages (SSBs) and processed meats and inadequate intake of nuts and whole grains also contribute to CVD risk. Clearly, achieving dietary change to improve CVD is a major challenge that needs to be addressed. Considering that most CVD is premature and can be prevented or delayed, the trillion-dollar question is "which interventions are most effective to improve diet and reduce CVD?" We propose to evaluate the comparative-effectiveness of evidence-based population interventions to improve diet (Aim 1). We will focus on population-level approaches as these are more sustainable and less costly compared to individual-level ones. We will select the most promising population interventions based on the results of our preliminary work, and quantify their effect sizes on diet based on pooling the published evidence. We will primarily focus on effect sizes for fruits and vegetables, dietary fats, salt, an SSBs. Depending on data availability, we will secondarily consider seafood omega-3 fats, nuts, whole grains, and processed meats. We will use the results of Aim 1 to subsequently evaluate the comparative-effectiveness of evidence-based population dietary interventions to reduce CVD mortality in the US by age and sex, using nationally-representative data (Aim 2). There is clearly an urgent need to develop a consistent methodology to compare the impact of different population interventions on CVD in the US context. As part of this effort, we will develop and extend from our prior work three different models. The assessment of the comparative-effectiveness of evidence-based population strategies to improve diet and reduce CVD, and the development of a consistent methodology to perform such an assessment, are each novel, and will provide essential insights for evidence-based preventive efforts in the US, and also identify important gaps for future studies. Application of that knowledge will be imperative in extending healthy life and reducing enormous and ever-increasing burdens of CVD in the US.