引用本文

代蘇堯, 楊帆, 胡逸凡, 肖雄. 不同膳食模式與常見(jiàn)慢性非傳染性疾病關(guān)系的研究進(jìn)展[J]. 中華流行病學(xué)雜志, 2021, 42(8): 1509-1517

Dai Suyao, Yang Fan, Hu Yifan, Xiao Xiong. Research progress on the relationship between dietary patterns and common noninfectious chronic diseases[J]. Chinese Journal of Epidemiology, 2021, 42(8): 1509-1517.

不同膳食模式與常見(jiàn)慢性非傳染性疾病關(guān)系的研究進(jìn)展

, 楊帆 , 胡逸凡 , 肖雄     

四川大學(xué)華西公共衛(wèi)生學(xué)院/華西第四醫(yī)院, 成都 610041

收稿日期: 2020-10-16

基金項(xiàng)目: 國(guó)家重點(diǎn)研發(fā)計(jì)劃（2017YFC0907305，2017YFC0907300）；國(guó)家自然科學(xué)基金（81903415）；四川省科技廳重點(diǎn)研發(fā)項(xiàng)目（2020YFS0215）；中國(guó)營(yíng)養(yǎng)學(xué)會(huì)-振東國(guó)人體質(zhì)與健康研究基金（CNS-ZD2020-149）

摘要: 隨著社會(huì)的發(fā)展，中國(guó)居民膳食模式逐漸趨向西式化，同時(shí)疾病譜也逐漸轉(zhuǎn)變?yōu)槁苑莻魅拘约膊?，如缺血性心臟病和腦卒中。飲食已被視為許多慢性疾病共同且可改變的影響因素。本研究通過(guò)檢索中、英文數(shù)據(jù)庫(kù)2015-2020年的文獻(xiàn)，從系統(tǒng)的角度梳理并整合了近年來(lái)膳食模式與心血管系統(tǒng)、代謝性疾病、消化系統(tǒng)、運(yùn)動(dòng)系統(tǒng)和精神系統(tǒng)的研究結(jié)局指標(biāo)、可能機(jī)制和研究結(jié)論等。本研究發(fā)現(xiàn)以紅肉及其加工肉類、快餐食品、含糖飲料等為特征的膳食模式是大多數(shù)疾病的危險(xiǎn)因素，而以蔬菜、水果、全谷物、魚(yú)等為特征的膳食模式是大多數(shù)疾病的保護(hù)因素。本文提出了膳食模式研究中應(yīng)注意的問(wèn)題，為后續(xù)的研究以及疾病的預(yù)防和干預(yù)提供科學(xué)依據(jù)。

關(guān)鍵詞: 膳食模式    慢性非傳染性疾病    

Research progress on the relationship between dietary patterns and common noninfectious chronic diseases

Dai Suyao , Yang Fan , Hu Yifan , Xiao Xiong     

West China School of Public Health and West China Forth Hospital, Sichuan University, Chengdu 610041, China

Fund program: National Key Research and Development Project of China (2017YFC0907305, 2017YFC0907300); National Natural Science Foundation of China (81903415); Key Research and Development Project of Science and Technology Department of Sichuan Province (2020YFS0215); Chinese Nutrition Society-Zhendong Human Fitness and Health Research Fund (CNS-ZD2020-149)

Abstract: With the development of society, the dietary pattern of Chinese residents gradually tends to be Westernized, and the disease spectrum has also been progressively changed into chronic non-communicable diseases like ischemic heart disease and stroke. Diet has been recognized as a common and modifiable factor for many chronic diseases. In this paper, the researches on dietary patterns and common chronic non-communicable diseases in recent years were summarized by searching the literature in Chinese and English databases in the past five years (2015-2020). This research integrated the outcome indicators, possible mechanisms, and research conclusions of dietary patterns and cardiovascular system, metabolic diseases, digestive system, locomotor system, and mental system in the past five years from the perspective of the human system. Dietary patterns characterized by red meat and processed meats, fast foods, sugary beverages were identified as risk factors for most diseases. In contrast, nutritional patterns characterized by vegetables, fruits, whole grains, fish were protective factors for most conditions. Meanwhile, it also put forward some problems that should be paid attention to in studying dietary patterns to provide a scientific basis for the follow-up research and the prevention and intervention of diseases.

Key words: Dietary pattern    Noninfectious chronic disease    

在過(guò)去20年里，隨著零售業(yè)和食品業(yè)的迅速發(fā)展，中國(guó)居民的飲食逐漸趨向“西式”及“現(xiàn)代化”[1]。人們更傾向于食用方便快捷的加工類食品或快餐，這些食品往往具有高油高糖的特點(diǎn)[2-3]。在疾病負(fù)擔(dān)方面，根據(jù)2019年最新疾病負(fù)擔(dān)研究數(shù)據(jù)顯示，自1990年以來(lái)，非傳染性疾病造成的傷殘損失壽命年比例顯著增加，其中腦卒中和缺血性心臟病為引起傷殘調(diào)整壽命年的前三位病因[4]。全球近1/5的死亡與不良飲食有關(guān)，飲食被公認(rèn)為許多慢性非傳染性疾病的共同且可改變的影響因素[5]，在慢性病的防治中扮演著重要角色。

傳統(tǒng)的營(yíng)養(yǎng)流行病學(xué)研究主要關(guān)注單一營(yíng)養(yǎng)素或食物的影響。近年來(lái)，膳食模式分析在營(yíng)養(yǎng)流行病學(xué)中的應(yīng)用逐漸興起[6]。膳食模式是指日常飲食中各種食物的數(shù)量及其在膳食中的相對(duì)構(gòu)成[7]。膳食模式研究將食物、營(yíng)養(yǎng)素作為整體進(jìn)行研究，與傳統(tǒng)的營(yíng)養(yǎng)流行病學(xué)研究相比，有如下優(yōu)勢(shì)：①能綜合考慮各種食物和營(yíng)養(yǎng)素間可能存在的相互作用；②某些營(yíng)養(yǎng)素（如鉀和鎂）之間存在高度關(guān)聯(lián)，因此很難檢測(cè)它們各自的影響，而膳食模式以飲食行為為基礎(chǔ)，這種共線性可以發(fā)揮優(yōu)勢(shì)；③單一營(yíng)養(yǎng)素的作用可能太小而無(wú)法檢測(cè)，但包含在飲食模式中的多種營(yíng)養(yǎng)素的累積作用可能增大到足以被檢測(cè)到[8]；④膳食模式的研究方法更有助于營(yíng)養(yǎng)干預(yù)如制定膳食指南，因?yàn)樯攀衬Ｊ奖葐我皇澄锘驙I(yíng)養(yǎng)素更容易讓公眾理解并實(shí)踐，因此更具有公共衛(wèi)生意義[6, 9]。

為明確常見(jiàn)膳食模式對(duì)人體系統(tǒng)健康的全面影響以及為今后膳食模式相關(guān)研究提供方向和指導(dǎo)，本研究通過(guò)檢索中、英文數(shù)據(jù)庫(kù)2015-2020年的文獻(xiàn)，對(duì)有關(guān)膳食模式與常見(jiàn)慢性非傳染性疾病的關(guān)系進(jìn)行梳理，并以幾個(gè)主要系統(tǒng)疾病為切入點(diǎn)展開(kāi)探討。

1. 膳食模式：膳食模式尚無(wú)確定的分類方法，不同國(guó)家和地區(qū)分類模式不一樣。因此本文根據(jù)不同分類方法確定的膳食模式進(jìn)行描述，目前常用的分類方法有先驗(yàn)法、后驗(yàn)法以及混合法。

（1）先驗(yàn)法：由國(guó)際組織或各國(guó)相關(guān)領(lǐng)域?qū)I(yè)人士制定的對(duì)個(gè)體食物攝入定量評(píng)分的量表，用于綜合評(píng)價(jià)個(gè)體的膳食攝入情況與某種膳食指南或科學(xué)飲食建議的一致情況，如地中海飲食評(píng)分、健康飲食指數(shù)（Healthy Eating Index，HEI）、國(guó)際膳食質(zhì)量指數(shù)（Diet Quality Index，DQI）、膳食平衡指數(shù)（Diet Balance Index，DBI）、飲食控制高血壓（Dietary Approaches to Stop Hypertension，DASH）評(píng)分等。目前研究中較常使用的膳食指數(shù)有替代健康飲食指數(shù)（Alternative Healthy Eating Index，AHEI）、地中海飲食評(píng)分、DASH評(píng)分等。幾乎所有膳食指數(shù)的正向指標(biāo)都包括蔬菜、水果、豆類，但也有不同的側(cè)重點(diǎn)。見(jiàn)表 1。AHEI-2010強(qiáng)調(diào)多不飽和脂肪酸的高攝入量，DASH飲食關(guān)注鈉、低脂奶制品的攝入，而地中海飲食強(qiáng)調(diào)不飽和脂肪酸、橄欖油和魚(yú)類的攝入，但并不像AHEI-2010和DASH飲食那樣限制鈉的攝入量。由表 1可知，除了DBI是依據(jù)《中國(guó)居民膳食指南》建立的，其余指數(shù)大部分基于歐美人群的飲食指南、預(yù)防特定疾病的指南或已知健康的飲食模式構(gòu)建的，在應(yīng)用和解釋膳食指數(shù)評(píng)分時(shí)，需要考慮膳食指數(shù)的依據(jù)、包含條目、截?cái)嘀殿愋?、取值類型、是否包含總能量攝入及能量是否需要校正、是否需要分性別或年齡計(jì)算、各條目權(quán)重等[10]，因此在評(píng)價(jià)研究人群的膳食質(zhì)量需要結(jié)合研究目的和數(shù)據(jù)類型綜合考慮進(jìn)行選擇。目前已有不少研究將DASH評(píng)分、地中海飲食評(píng)分、HEI評(píng)分應(yīng)用于亞洲人群研究中[11-13]。

表 1 常見(jiàn)先驗(yàn)膳食評(píng)分歸納表

（2）后驗(yàn)法：采用數(shù)據(jù)驅(qū)動(dòng)的方法如主成分分析、因子分析等提取出的膳食模式。如西方模式、謹(jǐn)慎模式[20]，由于研究數(shù)據(jù)來(lái)源不同以及方法的主觀抉擇，各膳食模式的命名及主要成分間存在交叉和不同。西方模式大多以紅肉及精加工肉類、含糖飲料、高脂奶制品、精制谷物為特征，常見(jiàn)于歐美地區(qū)。謹(jǐn)慎模式大多以蔬菜、水果、全谷物、魚(yú)類等為特征，常見(jiàn)于亞洲地區(qū)。由于后驗(yàn)膳食提取旨在最大化解釋食物的變異，因此可以提取出具有當(dāng)?shù)靥厣纳攀衬Ｊ?，但往往不具有外推性。目前已有研究基于中?guó)人群的數(shù)據(jù)提取膳食模式，Li和Shi[3]基于中國(guó)健康與營(yíng)養(yǎng)調(diào)查數(shù)據(jù)使用主成分分析提取出傳統(tǒng)膳食模式和現(xiàn)代膳食模式；而Yu等[21]基于中國(guó)慢性病前瞻性研究數(shù)據(jù)使用因子分析提取出傳統(tǒng)北方膳食模式和現(xiàn)代膳食模式。

（3）混合法：結(jié)合數(shù)據(jù)驅(qū)動(dòng)和先驗(yàn)知識(shí)得到的膳食模式，如降秩回歸法。降秩回歸法根據(jù)先驗(yàn)知識(shí)選擇與感興趣的疾病結(jié)局有關(guān)的指標(biāo)（如營(yíng)養(yǎng)素或者生化指標(biāo)）作為反應(yīng)變量，并采用數(shù)據(jù)驅(qū)動(dòng)的方法提取能最大限度解釋反應(yīng)變量變異的膳食模式，更直接地將膳食模式與感興趣的疾病聯(lián)系起來(lái)[22]。不同于描述性研究，在分析流行病學(xué)中關(guān)注的是膳食模式與疾病風(fēng)險(xiǎn)的關(guān)系，由于單純數(shù)據(jù)驅(qū)動(dòng)產(chǎn)生的后驗(yàn)膳食模式旨在解釋食物攝入的變異，往往不能成功地得出預(yù)測(cè)疾病的飲食模式，而通過(guò)降秩回歸法獲得的飲食模式旨在盡量解釋疾病特異性的營(yíng)養(yǎng)素或者生物標(biāo)志物的變異，能更好地闡明飲食在疾病病因?qū)W中的重要性。Frank等[23]在探究膳食模式與2型糖尿病關(guān)系時(shí)，根據(jù)已有先驗(yàn)知識(shí)即脂聯(lián)素、HDL-C和TG與2型糖尿病存在因果關(guān)聯(lián)，選擇這3種生物標(biāo)志物作為響應(yīng)變量納入降秩回歸，通過(guò)降維的方法得到能最大程度解釋這3種生物標(biāo)志物變異的因子（食物）的線性組合，即膳食模式。

2. 膳食模式與疾?。和ㄟ^(guò)文獻(xiàn)檢索，本研究發(fā)現(xiàn)目前國(guó)內(nèi)外膳食模式與疾病的關(guān)聯(lián)性研究主要集中在心血管系統(tǒng)、代謝性疾病、消化系統(tǒng)、精神系統(tǒng)、運(yùn)動(dòng)系統(tǒng)、女性及妊娠相關(guān)疾病、泌尿系統(tǒng)疾病等。由于篇幅限制，本研究將根據(jù)人體系統(tǒng)進(jìn)行分類，按照重要性分別對(duì)心血管系統(tǒng)、代謝性疾病、消化系統(tǒng)、精神系統(tǒng)、運(yùn)動(dòng)系統(tǒng)與膳食模式的研究進(jìn)行綜述。

雖然不同膳食模式對(duì)于各系統(tǒng)的疾病存在不同的影響，但是總體存在一些共性，即以紅肉及精加工肉類、快餐食品、含糖飲料等為特征的膳食模式是疾病的危險(xiǎn)因素，整體上呈高熱量、高脂肪、高碳水的特點(diǎn)，如西方模式、炎性膳食模式等；而以蔬菜、水果、全谷物、魚(yú)、豆類、堅(jiān)果等為特征的膳食模式是疾病的保護(hù)因素，如謹(jǐn)慎模式、地中海膳食模式等。本文接下來(lái)將對(duì)膳食模式對(duì)不同系統(tǒng)影響的特點(diǎn)進(jìn)行綜述。

（1）心血管系統(tǒng)：心血管系統(tǒng)中主要研究的結(jié)局有高血壓、腦卒中、缺血性心臟病、心肌梗塞、心力衰竭等疾病，而大部分膳食模式研究同時(shí)也關(guān)注心血管疾病的危險(xiǎn)因素如中心性肥胖、血脂異常等。

以紅肉及其制品、快餐、甜食、油、鹽等為特征的膳食模式與心血管疾病及其危險(xiǎn)因素呈正相關(guān)，此類膳食模式大多呈現(xiàn)高能量、高碳水、高脂肪、高鈉、低鉀、低鈣的特征[24-27]。以蔬菜、水果、堅(jiān)果、全谷物、豆類等為特征的膳食模式對(duì)心血管疾病及其危險(xiǎn)因素呈保護(hù)作用[24, 26, 28]，此類膳食模式呈低熱量、低脂肪、低碳水化合物和低鈉的特點(diǎn)，包含較多的膳食纖維、維生素和礦物質(zhì)（鈣、鎂、鉀、硒等）[29]。有研究認(rèn)為富含蛋白質(zhì)的膳食模式可以降低血壓[30]，可能是由于來(lái)源于食物蛋白質(zhì)的降壓肽對(duì)血壓的調(diào)節(jié)作用，也可能通過(guò)增加某些氨基酸如?；撬醽?lái)抑制血管緊張素Ⅱ?qū)a2+轉(zhuǎn)運(yùn)的作用，從而降低血壓[31]。

DASH飲食作為針對(duì)降低高血壓特地提出的膳食，在心血管風(fēng)險(xiǎn)上具有很好的保護(hù)作用。DASH飲食強(qiáng)調(diào)水果、蔬菜、脫脂或低脂奶制品、谷物、堅(jiān)果和豆類的攝入，限制紅肉和加工肉類、鹽和含糖飲料的攝入[17]，已被許多國(guó)家的糖尿病和心臟協(xié)會(huì)納入指南進(jìn)行廣泛推薦。DASH飲食能降低冠心病[25]、高血壓[32-33]、腦卒中[33]、腹主動(dòng)脈瘤[34]及其相關(guān)危險(xiǎn)因素的風(fēng)險(xiǎn)[25, 35]，可能與①富含鉀、鈣、鎂等已證明對(duì)血漿腎素活性與腎素-血管緊張素系統(tǒng)有影響的礦物質(zhì)；②含有某些植物化學(xué)物如具有抗炎、抗氧化、降低血管生成作用的黃酮類物質(zhì)；③降低血壓、糖化血紅蛋白和BMI等其他已確定的心血管疾病風(fēng)險(xiǎn)因素等復(fù)雜機(jī)制有關(guān)[35]。地中海飲食雖然不是特地針對(duì)心血管疾病提出的膳食模式，但在心血管疾病（如高血壓、冠心病、心源性猝死）及其危險(xiǎn)因素方面也具有保護(hù)作用[25, 36-38]，可能是炎癥、腸道菌群等復(fù)雜機(jī)制共同作用的結(jié)果[36]。

（2）代謝性疾病：飲食與體內(nèi)能量、糖、脂肪、蛋白質(zhì)等多種物質(zhì)代謝有關(guān)。目前大量研究均已證明，飲食是代謝性疾病發(fā)生發(fā)展的重要因素之一。在代謝性疾病中，主要研究的結(jié)局有2型糖尿病、超重或肥胖、MS、血脂異常等。

與代謝性疾病的發(fā)病有關(guān)的膳食模式大多以紅肉及加工肉類、油炸食品、快餐、甜品、精制谷物、酒精等為特征[39-41]，膳食模式整體上呈現(xiàn)高能量、高碳水、高脂肪的特點(diǎn)。而對(duì)代謝性疾病發(fā)病呈保護(hù)作用的膳食模式大多以蔬菜、水果、乳類及乳制品、全谷物、堅(jiān)果、魚(yú)蝦、禽肉等為特征[3, 42-43]。除共性外，與各疾病相關(guān)的膳食模式還呈現(xiàn)一些其他特點(diǎn)。與糖尿病發(fā)病有關(guān)的膳食模式大多包含高糖、高油脂食物和紅肉及加工肉類等[44-46]；與肥胖發(fā)病有關(guān)的膳食模式大多包含油炸食品、快餐、肉類等脂肪含量高的食物[47-49]；與血脂異常發(fā)病有關(guān)的膳食模式大多包含紅肉及加工肉、米飯、甜食等高碳水、高脂肪食物[50-52]；與高尿酸發(fā)病有關(guān)的膳食模式大多包含海鮮、內(nèi)臟、肉類、菌藻等高嘌呤食物[53-55]。

健康膳食模式評(píng)分如地中海膳食評(píng)分、DASH評(píng)分、AHEI與代謝性疾病的發(fā)病呈負(fù)相關(guān)。地中海飲食可以改善代謝性疾病相關(guān)指標(biāo)包括血糖、血脂、BMI等[44, 56-57]，但Mirmiran等[58]對(duì)伊朗2 241名成年人隨訪3年發(fā)現(xiàn)地中海飲食評(píng)分與MS無(wú)關(guān)，可能與非地中海國(guó)家和地中海國(guó)家存在食物可獲得性、食物營(yíng)養(yǎng)素構(gòu)成、食物加工和制備方面的差異有關(guān)。DASH飲食能降低高尿酸血癥、2型糖尿病、MS等代謝性疾病風(fēng)險(xiǎn)[44, 54, 59]。AHEI系列評(píng)分得分越高，肥胖、MS、糖尿病的患病風(fēng)險(xiǎn)越低[44, 60-61]。

（3）消化系統(tǒng)疾?。河捎谌祟愃鶖z入的食物均在消化系統(tǒng)進(jìn)行攝入、消化、吸收、排泄，因此消化系統(tǒng)疾病與膳食模式也存在密切關(guān)聯(lián)。在消化系統(tǒng)中主要研究的結(jié)局有胃癌、肝癌、食管癌、非酒精性脂肪肝、結(jié)直腸癌等。

以紅肉及精加工肉類、酒為主的膳食模式增加食道癌[62]、非酒精性脂肪肝、結(jié)直腸癌等患病風(fēng)險(xiǎn)，而以蔬菜、水果、全谷物為主的膳食模式對(duì)該類疾病具有保護(hù)作用。Bertuccio等[20]通過(guò)Meta分析發(fā)現(xiàn)在富含水果和蔬菜的“謹(jǐn)慎/健康”飲食和富含淀粉類食物、肉類和脂肪的“西式/不健康”飲食之間，胃癌風(fēng)險(xiǎn)的差異高達(dá)2倍。多項(xiàng)研究也發(fā)現(xiàn)非酒精性脂肪肝與食用全谷物、豆類、魚(yú)、蔬菜和水果呈負(fù)相關(guān)，而與食用精制谷物、紅肉及加工肉類、油炸食品呈正相關(guān)[63-64]。水果、蔬菜與結(jié)直腸癌風(fēng)險(xiǎn)呈負(fù)相關(guān)，而酒類、醬菜及腌制品類、紅肉類及禽肉類、油炸食品和飲料的攝入與結(jié)直腸癌的發(fā)生呈正相關(guān)[65-66]。Bravi等[67]對(duì)24項(xiàng)病例對(duì)照研究進(jìn)行梳理發(fā)現(xiàn)基于水果和蔬菜的飲食模式對(duì)上消化道癌癥存在有益作用，而基于肉類及其制品、酒精的模式可能出現(xiàn)不利的作用。

HEI[68-70]、DASH評(píng)分[71]、地中海飲食評(píng)分[68-70]與消化系統(tǒng)疾病風(fēng)險(xiǎn)呈負(fù)相關(guān)，即對(duì)健康的飲食模式依從性越高，患該類疾病的風(fēng)險(xiǎn)越低。但Li等[69]對(duì)494 968名美國(guó)人隨訪10年后發(fā)現(xiàn)HEI和調(diào)整地中海飲食評(píng)分與胃賁門(mén)癌或非賁門(mén)腺癌無(wú)顯著相關(guān)性。雖然食管、胃、肝、結(jié)直腸等在解剖學(xué)上屬于消化系統(tǒng)，且食管和胃屬于鄰近器官，但其與膳食的不同關(guān)聯(lián)反映了飲食在消化系統(tǒng)各器官中的可能存在不同抗炎、抗氧化能力或其他生物學(xué)機(jī)制。

（4）精神系統(tǒng)疾?。壕窠】捣矫媾c膳食模式相關(guān)的常見(jiàn)研究結(jié)局有認(rèn)知功能受損（障礙）、抑郁癥、阿爾茨海默病、失眠癥等。目前膳食模式已被認(rèn)為是影響精神系統(tǒng)疾病的重要發(fā)病因素之一。此外，由于精神系統(tǒng)健康與心血管健康間存在很多共病的生理基礎(chǔ)[72]，精神系統(tǒng)疾病（如抑郁癥、認(rèn)知功能下降等）和心血管疾病間也存在關(guān)聯(lián)[72]。心腦血管損傷程度與認(rèn)知功能受損呈正相關(guān)，膳食模式也可能通過(guò)影響血壓及心腦血管從而損傷認(rèn)知功能[72]。

以紅肉及其制品、油炸食品、含糖飲料等為特征的膳食模式是精神系統(tǒng)疾病的危險(xiǎn)因素。不健康的飲食如高脂飲食、高糖飲食會(huì)導(dǎo)致神經(jīng)退行性變，增加精神系統(tǒng)患病的風(fēng)險(xiǎn)[73-74]。對(duì)精神系統(tǒng)疾病有保護(hù)作用的膳食模式大多包含蔬菜、水果、全谷物等食物。抑郁、認(rèn)知功能、阿爾茨海默病與全身炎癥的上調(diào)和促氧化-抗氧化平衡的改變密切相關(guān)，而蔬菜、水果、魚(yú)蝦、堅(jiān)果中的抗氧化和抗炎物質(zhì)可能起到保護(hù)作用[73, 75-77]。膳食模式可能通過(guò)①抗炎和抗氧化機(jī)制，產(chǎn)生神經(jīng)保護(hù)作用；②食物中的營(yíng)養(yǎng)物質(zhì)對(duì)神經(jīng)營(yíng)養(yǎng)素的合成、突觸功能和神經(jīng)發(fā)生有促進(jìn)作用[78-79]；③改變細(xì)胞膜的流動(dòng)性和通透性[80]；④心腦血管相關(guān)的危險(xiǎn)因素[81]等復(fù)雜的機(jī)制對(duì)精神系統(tǒng)產(chǎn)生影響。

各類膳食指數(shù)相關(guān)研究均發(fā)現(xiàn)堅(jiān)持健康的飲食習(xí)慣與精神健康疾病呈負(fù)相關(guān)。DASH飲食可以降低認(rèn)知障礙、阿爾茨海默病、失眠癥的發(fā)病風(fēng)險(xiǎn)[73, 82-83]。堅(jiān)持地中海飲食模式可以降低認(rèn)知功能受損[82, 84]、阿爾茨海默病[73, 81]、精神障礙[85]、抑郁癥、焦慮癥等疾病[86]的發(fā)病風(fēng)險(xiǎn)。不過(guò)Shi等[87]對(duì)中國(guó)4 852名≥55歲成年人隨訪15年發(fā)現(xiàn)，雖然提取的膳食模式包含與地中海飲食相似的成分如蔬菜、豆類和全谷物，但沒(méi)有顯示出對(duì)認(rèn)知功能的保護(hù)作用，可能由于膳食模式中沒(méi)有魚(yú)和堅(jiān)果這些對(duì)認(rèn)知功能有益的食物成分，這也是地中海飲食的重要特征。

（5）運(yùn)動(dòng)系統(tǒng)疾病：研究與膳食模式相關(guān)的運(yùn)動(dòng)系統(tǒng)結(jié)局指標(biāo)主要有骨骼健康（如骨折、骨質(zhì)疏松等）和骨骼肌健康（肌肉功能降低、肌肉減少等）兩方面。

以紅肉及精加工肉類、甜品、含糖飲料、零食等為特征的膳食模式是骨骼及肌肉健康的危險(xiǎn)因素[88-89]，而對(duì)骨骼及肌肉健康有保護(hù)作用的膳食模式大多以雞蛋、豆類、奶及奶制品、蔬菜、水果、魚(yú)蝦等為特征[88-90]?？赡芘c以下機(jī)制有關(guān)：①膳食模式中充足的礦物質(zhì)（鈣、鉀、鎂）及蛋白質(zhì)對(duì)于骨骼健康如骨基質(zhì)的形成和維持具有促進(jìn)作用[91]；②食物中的營(yíng)養(yǎng)成分可以維持人體酸堿平衡，比如鎂和鉀可以緩沖導(dǎo)致骨吸收的酸性條件，防止骨質(zhì)流失[92]。水果和蔬菜等堿性食物預(yù)防酸中毒，保護(hù)肌肉質(zhì)量和力量[93]；③促炎細(xì)胞因子會(huì)導(dǎo)致破骨細(xì)胞的過(guò)度激活和成骨細(xì)胞活性的降低[94]，而蔬菜中的抗氧化劑如多酚對(duì)活性氧具有清除功能，減少氧化應(yīng)激，從而對(duì)骨骼健康起到保護(hù)作用。

各先驗(yàn)健康膳食指數(shù)對(duì)于骨骼健康的作用仍存在爭(zhēng)議。地中海飲食對(duì)骨骼及肌肉有保護(hù)作用[93, 95-96]，堅(jiān)持DASH飲食模式與患骨關(guān)節(jié)炎呈負(fù)相關(guān)[97]。也有研究認(rèn)為健康指數(shù)與運(yùn)動(dòng)系統(tǒng)之間關(guān)系尚不明確，Craig等[98]通過(guò)以往文獻(xiàn)進(jìn)行系統(tǒng)回顧和證據(jù)圖研究認(rèn)為目前缺乏可靠的證據(jù)表明地中海飲食和各個(gè)年齡段肌肉骨骼健康（骨折、骨密度、骨質(zhì)疏松和骨骼肌減少）之間的關(guān)系。Monjardino等[99]對(duì)1 180名青少年隨訪4年后未發(fā)現(xiàn)地中海飲食、DASH評(píng)分和前臂骨密度之間存在關(guān)聯(lián)，可能由于這些指南通常不是針對(duì)運(yùn)動(dòng)系統(tǒng)健康提出的，沒(méi)有捕捉到對(duì)運(yùn)動(dòng)系統(tǒng)健康起重要作用的食物組分。同時(shí)膳食模式中的食物組分互相作用也有可能抵消了某些食物的效應(yīng)，比如地中海飲食模式雖然包含蔬菜、水果等堿性物質(zhì)，但也包括谷類等酸性食物，后者可能抵消前者的堿性作用[99]。

3. 小結(jié)：本研究結(jié)果提示食用高營(yíng)養(yǎng)密度的食物如蔬菜、水果、全谷物、魚(yú)、豆類等。這些食物富含礦物質(zhì)、膳食纖維、n-3脂肪酸、抗氧化物等物質(zhì)，對(duì)于維護(hù)各大系統(tǒng)的健康均有益處[100]。此外，可以用更健康的油脂來(lái)源代替飽和脂肪酸，例如，可以用富含不飽和脂肪酸的植物油如橄欖油代替動(dòng)物脂肪如豬油。一些零食如爆米花、餅干和糕點(diǎn)也是飽和脂肪酸的重要膳食來(lái)源，可以選擇食品加工的油脂來(lái)調(diào)節(jié)飲食中的脂肪酸[101]。

膳食影響人體健康往往不是單一途徑的，對(duì)生理機(jī)制的探索一直處于研究中。本研究通過(guò)文獻(xiàn)梳理發(fā)現(xiàn)飲食對(duì)人體各大系統(tǒng)的影響既存在共性，也各有特點(diǎn)。膳食可能通過(guò)影響血壓、血糖-胰島素穩(wěn)態(tài)、血脂和脂蛋白濃度和功能、氧化應(yīng)激、全身炎癥、血管內(nèi)皮健康、凝血/血栓、肝臟功能、脂肪細(xì)胞功能、心臟功能、代謝消耗、大腦獎(jiǎng)勵(lì)、體重調(diào)節(jié)通路、內(nèi)臟脂肪、微生物等多種途徑影響心血管疾病和代謝性疾病的發(fā)病風(fēng)險(xiǎn)[102]。在消化系統(tǒng)方面，可能通過(guò)致癌/抑癌作用、腸道菌群、膽汁酸分泌、炎癥、氧化應(yīng)激、腸道屏障功能、脂代謝等途徑影響消化系統(tǒng)健康。在精神系統(tǒng)方面，可能通過(guò)影響炎癥反應(yīng)、氧化應(yīng)激、神經(jīng)細(xì)胞膜、腦源性神經(jīng)營(yíng)養(yǎng)因子、神經(jīng)遞質(zhì)、腦血管功能和腸道菌群等途徑產(chǎn)生影響[78, 80]。在運(yùn)動(dòng)系統(tǒng)方面，膳食可能通過(guò)影響炎癥反應(yīng)、氧化應(yīng)激、骨基質(zhì)的形成和維持、酸堿平衡等機(jī)制影響骨骼和肌肉的健康。上述各個(gè)系統(tǒng)中膳食模式均提到可能通過(guò)全身炎癥和氧化應(yīng)激來(lái)影響疾病的發(fā)生發(fā)展過(guò)程[103-104]。高脂肪、高碳水、高蛋白質(zhì)飲食與促進(jìn)炎性反應(yīng)的進(jìn)展有關(guān)。比如以精制谷物、紅肉及加工肉類、西式快餐、內(nèi)臟、含糖飲料等為特征的西方膳食模式，這類膳食模式富含糖、膽固醇、飽和脂肪酸等，與炎癥水平呈正相關(guān)[41, 104]。實(shí)驗(yàn)研究顯示高脂肪、高碳水化合物和高蛋白質(zhì)等飲食促進(jìn)炎癥反應(yīng)過(guò)程，炎性細(xì)胞因子促進(jìn)肝臟組織的慢性低度炎性反應(yīng)過(guò)程的發(fā)生發(fā)展[105]，而以蔬菜、水果、全谷物、豆類等為特征的膳食模式具有抗炎、抗氧化的作用[104, 106]。

需要注意的是，在本文中提到以某些食物為特征的膳食模式與某類疾病有關(guān)并不是特指某類食物與疾病有關(guān)，而是大部分研究關(guān)注的膳食模式的特征中提到了這類食物。因?yàn)槭澄锉旧韱为?dú)的效應(yīng)并不是本研究的研究范疇，而且某類食物的單獨(dú)效應(yīng)可能受到膳食模式中其他食物及食品組成、類型、品種和制備方法等的影響[37]。殷召雪等[107]研究發(fā)現(xiàn)以蔬菜攝入較多為特征的膳食模式與認(rèn)知功能損傷呈正相關(guān)，可能由于我國(guó)居民攝入的蔬菜通常是用鹽烹調(diào)或者腌制，隨著蔬菜攝入增加鈉鹽的攝入也增加，從而血壓水平上升，導(dǎo)致認(rèn)知功能受損。

部分研究得出與其他研究不一致的結(jié)論時(shí)，可以從以下幾方面進(jìn)行考慮和分析：①暴露的測(cè)量方法。大部分研究的膳食調(diào)查問(wèn)卷是自主設(shè)計(jì)的，未進(jìn)行信效度檢驗(yàn)或者信效度不高。同時(shí)，基于FFQ的調(diào)查問(wèn)卷很難包含調(diào)查對(duì)象所攝入的所有食物，不能反映真實(shí)的膳食模式；②暴露的測(cè)量偏倚。膳食調(diào)查中，調(diào)查對(duì)象往往傾向于高報(bào)健康食物的攝入量如水果、蔬菜，而低報(bào)一些不健康食物的攝入量如酒；③膳食模式的計(jì)算方法。先驗(yàn)指數(shù)評(píng)分計(jì)算方法、后驗(yàn)膳食模式因子提取方法、因子旋轉(zhuǎn)方法、因子得分計(jì)算方法等也會(huì)影響膳食模式的確定；④研究人群所在地域文化異質(zhì)性。不同國(guó)家、地區(qū)人群的基因異質(zhì)性、食物的可及性和營(yíng)養(yǎng)素構(gòu)成、不同文化對(duì)食物的食用偏好以及食品的加工和制備工藝不同都可能會(huì)影響飲食的整體健康效益[108]；⑤研究設(shè)計(jì)方面。橫斷面研究可能存在反向因果，只能說(shuō)明暴露和結(jié)局間存在關(guān)聯(lián)，而不具有因果推斷的能力；⑥研究對(duì)象的選擇。樣本量和納入排除標(biāo)準(zhǔn)均會(huì)影響研究結(jié)論的解讀和外推性；⑦關(guān)聯(lián)性分析。通常對(duì)膳食模式按照分位數(shù)進(jìn)行劃分，可能存在錯(cuò)分的情況。對(duì)于結(jié)局，可能由于未使用金標(biāo)準(zhǔn)判斷存在錯(cuò)分，或者自報(bào)結(jié)局不準(zhǔn)確的情況。此外，模型的混雜控制不足也可能影響結(jié)果。

本研究概述了近年來(lái)膳食模式研究的常見(jiàn)方法，并從人體系統(tǒng)的角度梳理并整合了近年來(lái)膳食模式與心血管系統(tǒng)、代謝性疾病、消化系統(tǒng)、運(yùn)動(dòng)系統(tǒng)和精神系統(tǒng)的研究結(jié)局指標(biāo)、可能機(jī)制和研究結(jié)論等，本研究發(fā)現(xiàn)以紅肉及其加工肉類、快餐食品、含糖飲料等為特征的膳食模式是大多數(shù)疾病的危險(xiǎn)因素，而以蔬菜、水果、全谷物、魚(yú)等為特征的膳食模式是大多數(shù)疾病的保護(hù)因素。對(duì)于大部分系統(tǒng)，健康的膳食模式（如DASH飲食、地中海飲食等）對(duì)人體健康具有保護(hù)作用，而少數(shù)系統(tǒng)與膳食模式（如運(yùn)動(dòng)系統(tǒng)與地中海模式）的結(jié)論仍存在爭(zhēng)議，需要臨床試驗(yàn)和大型前瞻性隊(duì)列在不同人群中進(jìn)行進(jìn)一步探索。同時(shí)本研究也提出了膳食模式研究中應(yīng)注意的問(wèn)題，為后續(xù)的研究以及疾病的預(yù)防和干預(yù)提供科學(xué)依據(jù)。

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