The Portfolio dietary pattern (also known as the “Dietary Portfolio” or “Portfolio Diet”) is a plant-based dietary pattern that was first developed in the early 2000s as a “portfolio” of cholesterol-lowering foods, each of which has a Food and Drug Administration (FDA), Health Canada, and/or European Food Safety Authority (EFSA) approved health claim for the reduction of cholesterol [1-7]. The original dietary pattern was built on a foundation of a low-saturated fat NCEP Step II diet (≤7% saturated fat, ≤200mg dietary cholesterol) with the addition of 4 cholesterol-lowering foods or pillars (based on a 2000 kcal diet): 45 g nuts (tree nuts or peanuts); 50 g plant protein (soy products or dietary pulses such as beans, peas, chickpeas, and lentils); 20 g viscous soluble fibre (oats, barley, psyllium, eggplant, and okra); and 2 g plant sterols (supplements or plant sterol-enriched products) [8-12]. The Portfolio dietary pattern has since been expanded and enhanced to include “heart healthy” monounsaturated fats (MUFA) as a 5th pillar (extra virgin olive oil, cold-pressed canola/soybean oils, or avocados) in replacement of high glycemic index carbohydrate (13% replacement providing 26% energy from MUFA) .
The biological basis for the intended cardiovascular risk reduction with the Portfolio diet is the “LDL-cholesterol (LDL-C) hypothesis”. There is now an established international consensus [14-16] that LDL-C is causal in the pathogenesis of atherosclerotic cardiovascular disease (ASCVD), based on multiple lines of high quality evidence from cardiovascular outcomes trials (through the Cholesterol Treatment Trialists Collaboration [CTTC] involving over 200,000 patients randomized to three different classes of drugs [statins, ezetimibe, PCSK9 inhibitors] ), Mendelian randomization studies of gain and loss of function mutations in the targets of these drugs that modify exposure to LDL-C (LDLR, HMGCR, NPC1L1, PCSK9)  and prospective cohort studies of the absolute magnitude of exposure to plasma LDL-C and the risk of ASCVD .
There is compelling evidence from randomized controlled trials that the Portfolio dietary pattern produces clinically meaningful reductions in LDL-C. The main clinical question tested in the early trials of the Portfolio diet was whether the small individual LDL-C effects of the cholesterol-lowering foods included in the pattern were additive. Updated systematic reviews and meta-analyses of randomized controlled trials continue to show that each component can lower LDL-C by 5-10% [20-32]. It was unclear whether these effects could be combined or summed in a single dietary pattern to produce a meaningful “drug-like” reduction in LDL-C. A series of randomized controlled trials were undertaken to address this question in which all foods were provided under metabolically controlled feeding conditions in people with hyperlipidemia [8-12]. These trials proved the efficacy of the Portfolio diet showing the predicted ~30% reductions in LDL-C [8-12]. A “head-to-head” trial with 1st line drug therapy further showed that the in-trial achieved reductions were similar to those seen with 20mg lovastatin (-28.6% versus -30.9%) (Figure 1) . A subsequent large multi-centre randomized controlled trial of effectiveness tested the question of whether the reductions in LDL-C were durable under real-world conditions over the longer-term, in which the Portfolio diet was administered as routine or intensive dietary advice (without provision of foods) over 6-months in people with hyperlipidemia . Although the reductions in LDL-C of 10-15% were smaller, this trial provided an important proof of concept, as the reductions were proportional to the adherence to the diet (the average adherence among participants was 43% to the original 4 pillars in the intensive arm) and remained clinically meaningful despite the lower adherence in both arms .
Figure 1. Effect of the Portfolio diet versus first-line therapy with a statin (20mg Lovastatin) on LDL-C in 46 participants with hyperlipidemia. Adapted from .
The strength of these findings was recently confirmed in a Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD) commissioned systematic review and meta-analysis of the available randomized controlled trials using the GRADE system to quantify and assess the certainty of the evidence for the effect of the Portfolio diet on ASCVD risk (Figure 2) . The pooled analysis of 7 trial comparisons in 439 participants with hyperlipidemia showed that Portfolio dietary pattern lowered the primary outcome LDL-C by 17% (21% in efficacy and 12% in effectiveness trials) compared with the NCEP Step II diet alone with high certainty evidence. It was calculated that the intended combination with an NCEP Step II diet would be expected to produce LDL-C reductions of ~27% (33% in efficacy and 15% in effectiveness trials) in clinical practice, reductions which would exceed the lower limit of efficacy of 1st line therapy with statins (20%) and the upper limit of efficacy of 2nd line therapy with ezetimibe (22%) . Advantages beyond LDL-C were also seen with moderate to high certainty evidence in support of improvements in other atherogenic aspects of the lipid profile (-14% non-HDL-C, -15% apoB, -16% triglycerides), blood pressure (-1.75 mmHg SBP), and inflammation (-32% CRP) culminating in a reduction in estimated 10-year CHD risk by the Framingham Risk Score of ~13% (20% in efficacy and 9% in effectiveness trials).
Figure 2. Pooled effect of the Portfolio diet on LDL-C and various cardiometabolic risk factors. Data are based on meta-analyses of 7 randomized controlled trial comparisons in 439 participants. Adapted from .
Taken together, the evidence from the individual randomized controlled trials and the systematic reviews and meta-analyses of the randomized controlled trials has contributed to widespread recognition of the benefits of the Portfolio diet from major international heart and diabetes clinical practice guidelines. These include the clinical practice guidelines of the Canadian Cardiovascular Society (CCS) , Diabetes Canada , Heart UK , Heart Foundation of Australia , the American College of Cardiology /American Heart Association , and the European Atherosclerosis Society (EAS)  (Table 1), while each of the food components have been recognized for their LDL-C lowering by the joint task force of the European Society of Cardiology (ESC) and EAS .
To aid in the implementation of the Portfolio diet in clinical practice, our team developed a number of patient and physician engagement tools as a direct translation of the clinical practice guidelines. First, a Portfolio diet infographic (https://ccs.ca/app/uploads/2020/11/Portfolio_Diet_Scroll_editable_eng.pdf) as developed in partnership with the University of Toronto, St. Michael’s Hospital, and the Canadian Cardiovascular Society (CCS). This mobile-based Portfolio Diet App and included patient education materials (tip sheets, videos and recipes) have also been developed with the support of the CCS and will be hosted on their website. A book (including scientific background and recipes) was also recently published .
Despite the international consensus on the LDL-C hypothesis and the evidence in support of the Portfolio diet for LDL-C-and ASCVD risk reduction, there remains a need for more research on harder CV outcomes. Large randomized trials (cardiovascular outcomes trials) of the effect of the Portfolio dietary pattern on the progression of atherosclerosis will be important to assess whether the reductions in LDL-C and other established cardiometabolic risk factors with the Portfolio diet translate into reductions in clinical CV events. We await the results of the Combined Portfolio Diet and Exercise Study (PortfolioEx trial), a 3-year multicentre randomized controlled trial of the effect of the Portfolio diet plus exercise on carotid plaque burden, assessed by vascular magnetic resonance imaging (MRI) in high CV risk people 50% of whom have diabetes (ClinicalTrials.gov Identiﬁer, NCT02481466).
Table 1. International heart and diabetes clinical practice guidelines supporting the Portfolio diet for LDL-C and atherosclerotic cardiovascular disease (ASCVD) risk reduction [35-40].
Heart or diabetes association
Useful links from the Canadian Cardiovascular Society:
For companion resources, click here.
For the Portfolio Diet infographic, click here.
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