美国预防服务工作组证据更新报告和系统评审
饮食习惯不健康、体力活动少、久坐，可增加心血管疾病风险。
2017年7月11日，《美国医学会杂志》正式发表凯萨医疗机构（俄勒冈波特兰）卫生研究中心为美国预防服务工作组（USPSTF）更新的证据报告和系统评审：行为咨询促进健康饮食和体力活动对无已知心血管疾病风险因素成人的心血管疾病预防作用。
美国预防服务工作组（USPSTF）是由美国卫生部医疗研究与质量管理局任命的初级医疗、流行病学和预防医学专家组，负责对临床预防服务的有效证据进行系统评审并制定推荐意见。USPSTF不考虑成本效益。推荐意见单纯基于患者医疗获益证据，无论成本高低。
凯萨医疗机构是一家综合性管理型医疗集团，总部位于美国加利福尼亚州奥克兰，由实业家亨利·凯萨和医生西德尼·加菲尔德于1945年创立，由三个不同但是相互依赖的实体组成：凯萨基金会医疗保险公司及其区域运营子公司、凯萨基金会医院、区域医生集团（医疗团队执业经纪组织）。截至2014年，凯萨医疗机构在八个州以及哥伦比亚特区经营，是美国最大的管理型医疗集团。
本文对无已知心血管风险因素成人的心血管疾病初级预防行为咨询利弊证据进行了系统评审，并向USPSTF汇报。数据来自2013年1月1日～2016年5月25日MEDLINE、PubMed、Cochrane对照研究登记中心、PsycINFO数据库以英文发表的研究，以及对目标出版物至2017年3月24日的持续监测。既往评审纳入的研究也被重新评估。选择针对改善饮食、增加体力活动、减少久坐时间或其组合干预无已知高血压、高血脂、糖尿病或空腹血糖超标成人行为的随机临床研究，由2位评审者进行独立的严格评价和数据提取。主要评价指标为心脏代谢健康和中间结局、行为结局、干预相关危害。共从145种出版物筛选出88项研究（样本量121190）。
结果发现，干预对全部原因或心血管原因所致死亡率或发病率（4项研究，样本量51356）或健康相关生活质量（10项研究，样本量52423）的获益不一。
有证据表明，干预组与对照组相比，6～12个月时，以下指标的组间平均差异有少量统计学意义，并且与饮食和体力活动行为有小到中等相关性：
收缩压降低（-1.26mmHg，95%置信区间：-1.77～-0.75，22项研究，样本量57953）
舒张压降低（-0.49mmHg，95%置信区间：-0.82～-0.16，23项研究，样本量58022）
低密度脂蛋白胆固醇水平降低（-2.58mg/dL，95%置信区间：-4.30～-0.85，13项研究，样本量5554）
总胆固醇水平降低（-2.85mg/dL，95%置信区间：-4.95～-0.75，19项研究，样本量9325）
体重指数降低（-0.41，95%置信区间：-0.62～-0.19，20项研究，样本量55059）
无证据表明，干预组与对照组相比，严重不良事件、损伤或跌倒发生率较高。
因此，对于无心血管疾病高风险成人的饮食和体力活动行为干预，可以在6～12个月内对各种重要中间健康结局（包括血压、低密度脂蛋白和总胆固醇水平、肥胖）一致产生一定程度获益，并有量效作用证据，表明较高强度干预可以带来较大改善。关于这些干预措施对长期中间和健康结局有利或有害影响的证据非常有限。
对此，《美国医学会杂志》配发患者单页：无风险因素成人预防心血管疾病的健康生活咨询。
对此，《美国医学会杂志》配发西北大学费恩伯格医学院、纽约西奈山伊坎医学院、西班牙卡洛斯三世国家心血管研究中心、《美国医学会杂志》高级编辑的同期评论：为所有人控制心血管风险因素。
当天，《美国医学会杂志心脏病学分册》在线发表西北大学费恩伯格医学院预防医学专家的评论：推广健康的体力活动和饮食——为了多数人或少数人？
当天，《美国医学会杂志内科学分册》在线发表英国利物浦大学临床流行病学和初级医疗专家的评论：对无已知风险因素成人进行预防心血管疾病的健康饮食和体力活动行为咨询是否必要？
调查投票
JAMA. 2017 Jul 11;318(2):175-193.
Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.
Patnode CD, Evans CV, Senger CA, Redmond N, Lin JS.
Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon.
IMPORTANCE: Unhealthful dietary patterns, low levels of physical activity, and high sedentary time increase the risk of cardiovascular disease.
OBJECTIVE: To systematically review the evidence on the benefits and harms of behavioral counseling for the primary prevention of cardiovascular disease in adults without known cardiovascular risk factors to inform the US Preventive Services Task Force.
DATA SOURCES: MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and PsycINFO for studies published in the English language between January 1, 2013, and May 25, 2016, and ongoing surveillance in targeted publications through March 24, 2017. Studies included in the previous review were reevaluated for inclusion.
STUDY SELECTION: Randomized clinical trials of behavioral interventions targeting improved diet, increased physical activity, decreased sedentary time, or a combination of these among adults without known hypertension, dyslipidemia, diabetes, or impaired fasting glucose.
DATA EXTRACTION AND SYNTHESIS: Independent critical appraisal and data abstraction by 2 reviewers.
MAIN OUTCOMES AND MEASURES: Cardiometabolic health and intermediate outcomes, behavioral outcomes, and harms related to interventions.
RESULTS: Eighty-eight studies (N=121190) in 145 publications were included. There was no consistent benefit of the interventions on all-cause or cardiovascular mortality or morbidity (4 trials [n=51356]) or health-related quality of life (10 trials [n=52423]). There was evidence of small, statistically significant between-group mean differences for systolic blood pressure (-1.26 mm Hg [95% CI, -1.77 to -0.75]; 22 trials [n=57953]), diastolic blood pressure (-0.49 mm Hg [95% CI, -0.82 to -0.16]; 23 trials [n=58022]), low-density lipoprotein cholesterol level (-2.58 mg/dL [95% CI, -4.30 to -0.85]; 13 trials [n=5554]), total cholesterol level (-2.85 mg/dL [95% CI, -4.95 to -0.75]; 19 trials [n=9325]), and body mass index (-0.41 [95% CI, -0.62 to -0.19]; 20 trials [n=55059]) at 6 to 12 months as well as small-to-modest associations with dietary and physical activity behaviors. There was no evidence of greater incidence of serious adverse events, injuries, or falls in intervention vs control participants.
CONCLUSIONS AND RELEVANCE: Diet and physical activity behavioral interventions for adults not at high risk for cardiovascular disease result in consistent modest benefits across a variety of important intermediate health outcomes across 6 to 12 months, including blood pressure, low-density lipoprotein and total cholesterol levels, and adiposity, with evidence of a dose-response effect, with higher-intensity interventions conferring greater improvements. There is very limited evidence on longer-term intermediate and health outcomes or on harmful effects of these interventions.
PMID: 28697259
DOI: 10.1001/jama.2017.3303
JAMA. 2017 Jul 11;318(2):210.
Counseling on Healthy Living to Prevent Cardiovascular Disease in Adults Without Risk Factors.
Jin J.
PMID: 28697255
DOI: 10.1001/jama.2017.8445
JAMA. 2017 Jul 11;318(2):130-131.
Cardiovascular Risk Factor Control for All.
Greenland P, Fuster V.
Northwestern University Feinberg School of Medicine, Chicago, Illinois; Senior Editor, JAMA; Icahn School of Medicine at Mount Sinai, New York, New York; Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.
PMID: 28697239
DOI: 10.1001/jama.2017.7648
JAMA Cardiol. 2017 Jul 11. [Epub ahead of print]
Healthful Physical Activity and Diet Promotion-For the Many or the Few?
Spring B.
Northwestern University Feinberg School of Medicine, Preventive Medicine, Chicago, Illinois.
PMID: 28697230
DOI: 10.1001/jamacardio.2017.2568
JAMA Intern Med. 2017 Jul 11. [Epub ahead of print]
Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Risk Factors: Is Behavioral Counselling Necessary?
Capewell S, Dowrick C.
University of Liverpool, United Kingdom.
PMID: 28697229
DOI: 10.1001/jamainternmed.2017.1979