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) [13].

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] [17]), 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) [18] and prospective cohort studies of the absolute magnitude of exposure to plasma LDL-C and the risk of ASCVD [19].

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) [10]. 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 [13].  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 [13].

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 [10].

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) [33]. 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%) [34]. 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 [33].

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) [35],  Diabetes Canada [36], Heart UK [37], Heart Foundation of Australia [38],  the American College of Cardiology /American Heart Association [39], and the European Atherosclerosis Society (EAS) [40] (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 [41].

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 [42].

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 Identi?er, 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

Guidance

Useful links from the Canadian Cardiovascular Society:

For companion resources, click here.

For the Portfolio Diet infographic, click here.

References

  1. Food Directorate Health Products and Food Branch, Health Canada. Plant sterols and blood cholesterol lowering. Ottawa: Bureau of Nutritional Sciences. 21 May 2010. Available: https://www.canada.ca/en/health-canada/services/food-nutrition/food-labelling/health-claims/assessments/plant-sterols-blood-cholesterol-lowering-nutrition-health-claims-food-labelling.html.
  2. Food Directorate, Health Products and Food Branch, Health Canada. Summary of Health Canada’s assessment of a health claim about soy protein and cholesterol lowering. Ottawa: Bureau of Nutritional Sciences. March 2015. Available: https://www.canada.ca/en/health-canada/services/food-nutrition/food-labelling/health-claims/assessments/summary-assessment-health-claim-about-protein-cholesterol-lowering.html.
  3. Food Directorate Health Products and Food Branch, Health Canada. Oat products and blood cholesterol lowering. Ottawa: Bureau of Nutritional Sciences. 2010.
  4. Food Directorate, Health Products and Food Branch, Health Canada. List of dietary fibres reviewed and accepted by Health Canada’s Food Directorate. Ottawa: Bureau of Nutritional Sciences. May 2017. Available: https://www.canada.ca/en/health-canada/services/publications/food-nutrition/list-reviewed-accepted-dietary-fibres.html.
  5. U.S. Food & Drug Administration. Qualified Health Claims: letter of enforcement discretion – nuts and coronary heart disease (Docket No 02P-0505). 14 July 2003. Available: http://wayback.archive-it.org/7993/20171114183724/https://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm072926.htm.
  6. EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA); Scientific Opinion on the substantiation of a health claim related to 3 g/day plant sterols/stanols and lowering blood LDL-cholesterol and reduced risk of (coronary) heart disease pursuant to Article 19 of Regulation (EC) No 1924/2006. EFSA Journal 2012;10(5):2693. [13 pp.]. doi:10.2903/j.efsa.2012.2693. Available online: http://www.efsa.europa.eu/efsajournal.
  7. EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA); Scientific Opinion on the substantiation of a health claim related to oat beta-glucan and lowering blood cholesterol and reduced risk of (coronary) heart disease pursuant to Article 14 of Regulation (EC) No 1924/2006. EFSA Journal 2010;8(12):1885. [15 pp.] doi:10.2903/j.efsa.2010.1885. Available online: http://www.efsa.europa.eu/efsajournal.htm.
  8. Jenkins DJ, Kendall CW, Faulkner D, Vidgen E, Trautwein EA, Parker TL, Marchie A, Koumbridis G, Lapsley KG, Josse RG, Leiter LA and Connelly PW. A dietary portfolio approach to cholesterol reduction: combined effects of plant sterols, vegetable proteins, and viscous fibers in hypercholesterolemia. Metabolism: clinical and experimental. 2002;51:1596-604.
  9. Jenkins DJ, Kendall CW, Marchie A, Faulkner D, Vidgen E, Lapsley KG, Trautwein EA, Parker TL, Josse RG, Leiter LA and Connelly PW. The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia. Metabolism: clinical and experimental. 2003;52:1478-83.
  10. Jenkins DJ, Kendall CW, Marchie A, Faulkner DA, Wong JM, de Souza R, Emam A, Parker TL, Vidgen E, Lapsley KG, Trautwein EA, Josse RG, Leiter LA and Connelly PW. Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. JAMA. 2003;290:502-10.
  11. Jenkins DJ, Kendall CW, Faulkner DA, Nguyen T, Kemp T, Marchie A, Wong JM, de Souza R, Emam A, Vidgen E, Trautwein EA, Lapsley KG, Holmes C, Josse RG, Leiter LA, Connelly PW and Singer W. Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia. The American journal of clinical nutrition. 2006;83:582-91.
  12. Jenkins DJ, Jones PJ, Lamarche B, Kendall CW, Faulkner D, Cermakova L, Gigleux I, Ramprasath V, de Souza R, Ireland C, Patel D, Srichaikul K, Abdulnour S, Bashyam B, Collier C, Hoshizaki S, Josse RG, Leiter LA, Connelly PW and Frohlich J. Effect of a dietary portfolio of cholesterol-lowering foods given at 2 levels of intensity of dietary advice on serum lipids in hyperlipidemia: a randomized controlled trial. JAMA. 2011;306:831-9.
  13. Jenkins DJ, Chiavaroli L, Wong JM, Kendall C, Lewis GF, Vidgen E, Connelly PW, Leiter LA, Josse RG and Lamarche B. Adding monounsaturated fatty acids to a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia. CMAJ  2010;182:1961-7.
  14. Boren J, Chapman MJ, Krauss RM, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J 2020.
  15. Ference BA, Ginsberg HN, Graham I, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J 2017;38:2459-72.
  16. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;74:1376-414.
  17. Ference BA, Cannon CP, Landmesser U, Luscher TF, Catapano AL, Ray KK. Reduction of low density lipoprotein-cholesterol and cardiovascular events with proprotein convertase subtilisin-kexintype 9 (PCSK9) inhibitors and statins: an analysis of FOURIER, SPIRE, and the Cholesterol Treatment Trialists Collaboration. Eur Heart J 2018;39:2540-5.
  18. Ference BA, Majeed F, Penumetcha R, Flack JM, Brook RD. Effect of naturally random allocation to lower low-density lipoprotein cholesterol on the risk of coronary heart disease mediated by polymorphisms in NPC1L1, HMGCR, or both: a 2 × 2 factorial Mendelian randomization study. J Am Coll Cardiol. 2015 Apr 21;65(15):1552-61.
  19. Emerging Risk Factors Collaboration, Di Angelantonio E, Gao P, Pennells L, Kaptoge S, Caslake M, Thompson A, Butterworth AS, Sarwar N, Wormser D, Saleheen D, Ballantyne CM, Psaty BM, Sundström J, Ridker PM, Nagel D, Gillum RF, Ford I, Ducimetiere P, Kiechl S, Koenig W, Dullaart RP, Assmann G, D’Agostino RB Sr, Dagenais GR, Cooper JA, Kromhout D, Onat A, Tipping RW, Gómez-de-la-Cámara A, Rosengren A, Sutherland SE, Gallacher J, Fowkes FG, Casiglia E, Hofman A, Salomaa V, Barrett-Connor E, Clarke R, Brunner E, Jukema JW, Simons LA, Sandhu M, Wareham NJ, Khaw KT, Kauhanen J, Salonen JT, Howard WJ, Nordestgaard BG, Wood AM, Thompson SG, Boekholdt SM, Sattar N, Packard C, Gudnason V, Danesh J. Lipid-related markers and cardiovascular disease prediction. JAMA. 2012 Jun 20;307(23):2499-506.
  20. Ho HV, Sievenpiper JL, Zurbau A, Mejia SB, Jovanovski E, Au-Yeung F, Jenkins AL, Vuksan. A systematic review and meta-analysis of randomized controlled trials of the effect of barley ?-glucan on LDL-C, non-HDL-C and apoB for cardiovascular disease risk reduction. Eur J Clin Nutr. 2016 Nov;70(11):1239-1245.
  21. Ho HVT, Jovanovski E, Zurbau A, Blanco Mejia S, Sievenpiper JL, Au-Yeung F, Jenkins AL, Duvnjak L, Leiter L, Vuksan V. A systematic review and meta-analysis of randomized controlled trials of the effect of konjac glucomannan, a viscous soluble fiber, on LDL cholesterol and the new lipid targets non-HDL cholesterol and apolipoprotein B. Am J Clin Nutr. 2017 May;105(5):1239-1247.
  22. Brown L, Rosner B, Willett WW and Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. The American journal of clinical nutrition. 1999;69:30-42.
  23. Blanco Mejia S, Messina M, Li SS, Viguiliouk E, Chiavaroli L, Khan TA, Srichaikul K, Mirrahimi A, Sievenpiper JL, Kris-Etherton P, Jenkins DJA. A Meta-Analysis of 46 Studies Identified by the FDA Demonstrates that Soy Protein Decreases Circulating LDL and Total Cholesterol Concentrations in Adults. J Nutr. 2019 Jun 1;149(6):968-981
  24. Jenkins DJA, Blanco Mejia S, Chiavaroli L, Viguiliouk E, Li SS, Kendall CWC, Vuksan V, Sievenpiper JL. Cumulative Meta-Analysis of the Soy Effect Over Time. J Am Heart Assoc. 2019 Jul 2;8(13):e012458.
  25. Li SS, Blanco Mejia S, Lytvyn L, Stewart SE, Viguiliouk E, Ha V, de Souza RJ, Leiter LA, Kendall CWC, Jenkins DJA, Sievenpiper JL. Effect of Plant Protein on Blood Lipids: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc. 2017 Dec 20;6(12):e006659.
  26. Ha V, Sievenpiper JL, de Souza RJ, Jayalath VH, Mirrahimi A, Agarwal A, Chiavaroli L, Mejia SB, Sacks FM, Di Buono M, Bernstein AM, Leiter LA, Kris-Etherton PM, Vuksan V, Bazinet RP, Josse RG, Beyene J, Kendall CW, Jenkins DJ. Effect of dietary pulse intake on established therapeutic lipid targets for cardiovascular risk reduction: a systematic review and meta-analysis of randomized controlled trials. CMAJ. 2014 May 13;186(8):E252-62.
  27. Law M. Plant sterol and stanol margarines and health. BMJ (Clinical research ed). 2000;320:861-4.
  28. Abumweis SS, Barake R, Jones PJ. Plant sterols/stanols as cholesterol lowering agents: A meta-analysis of randomized controlled trials. Food Nutr Res. 2008;52.
  29. Ras RT, Geleijnse JM, Trautwein EA. LDL-cholesterol-lowering effect of plant sterols and stanols across different dose ranges: a meta-analysis of randomised controlled studies. Br J Nutr. 2014 Jul 28;112(2):214-9.
  30. Sabate J, Oda K, Ros E. Nut consumption and blood lipid levels: A Pooled Analysis of 25 Intervention Trials. Arch Intern Med 2010;170:821-7.
  31. Musa-Veloso K, Paulionis L, Poon T, Lee HY. The effects of almond consumption on fasting blood lipid levels: a systematic review and meta-analysis of randomised controlled trials. J Nutr Sci. 2016 Aug 16;5:e34.
  32. Liu K, Hui S, Wang B, Kaliannan K, Guo X, Liang L. Comparative effects of different types of tree nut consumption on blood lipids: a network meta-analysis of clinical trials. Am J Clin Nutr. 2020 Jan 1;111(1):219-227.
  33. Chiavaroli L, Nishi SK, Khan TA, Braunstein CR, Glenn AJ, Mejia SB, Raheli? D, Kahleová H, Salas-Salvadó J, Jenkins DJA, Kendall CWC, Sievenpiper JL. Portfolio Dietary Pattern and Cardiovascular Disease: A Systematic Review and Meta-analysis of Controlled Trials. Prog Cardiovasc Dis. 2018 May-Jun;61(1):43-53.
  34. Li YH, Ueng KC, Jeng JS, Charng MJ, Lin TH, Chien KL, Wang CY, Chao TH, Liu PY, Su CH, Chien SC, Liou CW, Tang SC, Lee CC, Yu TY, Chen JW, Wu CC, Yeh HI; Writing Group of 2017 Taiwan Lipid Guidelines for High Risk Patients. 2017 Taiwan lipid guidelines for high risk patients. J Formos Med Assoc. 2017 Apr;116(4):217-248. doi: 10.1016/j.jfma.2016.11.013.
  35. Anderson TJ, Gregoire J, Pearson GJ, Barry AR, Couture P, Dawes M, Francis GA, Genest J, Jr., Grover S, Gupta M, Hegele RA, Lau DC, Leiter LA, Lonn E, Mancini GB, McPherson R, Ngui D, Poirier P, Sievenpiper JL, Stone JA, Thanassoulis G and Ward R. 2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. The Canadian journal of cardiology. 2016;32:1263-1282.
  36. Sievenpiper JL, Chan CB, Dworatzek PD, Freeze C and Williams SL. Nutrition Therapy. Canadian journal of diabetes. 2018;42 Suppl 1:S64-s79.
  37. Heart UK: The cholesterol charity. Portfolio Diet. Accessed at https://www.heartuk.org.uk/downloads/healthprofessionals/factsheets/the-portfolio-diet.pdf
  38. National Heart Foundation of Australia. Cardiac Rehabilitation Program Outline – Module 6. Healthy eating and weight management. Accessed at https://www.heartfoundation.org.au/getmedia/7d0cdb2c-6884-4912-9bf0-00cb207c71f1/CardRehabMod6_HealthEating_FINAL.pdf
  39. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC Jr, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Jun 18;139(25):e1182-e1186]. Circulation. 2019;139(25):e1082?e1143.
  40. Stroes ES, Thompson PD, Corsini A, Vladutiu GD, Raal FJ, Ray KK, Roden M, Stein E, Tokgozoglu L, Nordestgaard BG, Bruckert E, De Backer G, Krauss RM, Laufs U, Santos RD, Hegele RA, Hovingh GK, Leiter LA, Mach F, Marz W, Newman CB, Wiklund O, Jacobson TA, Catapano AL, Chapman MJ and Ginsberg HN. Statin-associated muscle symptoms: impact on statin therapy-European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management. European heart journal. 2015;36:1012-22.
  41. Catapano AL, Graham I, De Backer G, Wiklund O, Chapman MJ, Drexel H, Hoes AW, Jennings CS, Landmesser U, Pedersen TR, Reiner Ž, Riccardi G, Taskinen MR, Tokgozoglu L, Monique Verschuren WM, Vlachopoulos C, Wood DA, Luis Zamorano J; Additional Contributor, Cooney MT. 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias. Rev Esp Cardiol (Engl Ed). 2017 Feb;70(2):115.
  42. Jenkins WM, Jenkins AE, Jenkins AL, Brydson C. The Portfolio Diet for Cardiovascular Disease Risk Reduction: An Evidence Based Approach to Lower Cholesterol through Plant Food Consumption. Academic Press, Nov 2019.
en_CAEnglish