About the Portfolio Diet: For Health Care Professionals

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 5e pilier (huile d’olive extra vierge, huiles de canola/soja pressées à froid, ou avocats) en remplacement des glucides à indice glycémique élevé (remplacement de 13 % fournissant 26 % d’énergie provenant des AGMIs) [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 1er intention a également montré que les réductions obtenues au cours de l’essai étaient similaires à celles observées avec 20 mg de lovastatine (-28,6 % contre -30,9 %) (Figure 1) [10]. Un vaste essai randomisé contrôle multicentrique subséquent a permis de vérifier si les réductions du taux de LDL-C étaient durables à long terme dans des conditions réelles. Dans cet essai, le régime Portfolio a été administré sous forme de conseils diététiques de routine ou intensifs (sans apport de nourriture) pendant 6 mois à des personnes souffrant d’hyperlipidémie [13]. Bien que les réductions du taux de LDL-C de 10 à 15 % aient été plus faibles, cet essai a fourni une preuve importante du concept, car les réductions étaient proportionnelles à l’adhésion au régime (l’adhésion moyenne des participants était de 43 % aux 4 piliers originaux dans le groupe intensif) et sont restées cliniquement significatives malgré une adhésion plus faible dans les deux groupes [13].

Figure 1. Effet du régime Portfolio contre thérapie de première intention avec une statine (20 mg de Lovastatine) sur le LDL-C chez 46 participants souffrant d’hyperlipidémie. Adapté de [10].

La solidité de ces découvertes a été récemment confirmée par une revue systématique et une méta-analyse des essais contrôlés randomisés disponibles commandés par le Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD), qui a utilisé le système GRADE pour quantifier et évaluer la certitude des preuves de l’effet du régime Portfolio sur le risque de MCAV ) (Figure 2) [33]. L’analyse groupée de 7 essais comparatifs chez 439 participants atteints souffrant d’hyperlipidémie a montré que le régime Portfolio réduisait le critère de jugement principal LDL-C de 17 % (21 % dans les essais d’efficacité et 12 % dans les essais d’efficience) par rapport au régime NCEP Step II seul, avec un degré de certitude élevé. Il a été calculé que la combinaison prévue avec un régime de NCEP Step II devrait produire des réductions du LDL-C d’environ 27 % (33 % dans les essais d’efficacité et 15 % dans les essais d’efficience) dans la pratique clinique, réductions qui dépasseraient la limite inferieure d’efficacité de la thérapie de 1er intention par les statines (20 %) et la limite supérieure d’efficacité de la thérapie de 2e intention par l’ézétimibe (22 %) [34]. Des avantages au-delà de LDL-C ont également été observés avec des preuves de certitudes modérée à élevée en faveur d’améliorations d’autres aspects athérogènes du profil lipidique (-14 % de non-HDL-C, -15 % d’apoB, -16 % de triglycérides), de la pression artérielle (-1,75 mmHg SBP) et de l’inflammation (-32 % CRP), aboutissant à une réduction du risque estimé de coronaropathie à 10 ans selon le score de risque de Framingham de ~13 % (20 % dans les essais d’efficacité et 9 % dans les essais d’efficience).

Figure 2. Effet groupé du régime Portfolio sur le LDL-C et divers facteurs de risque cardiométabolique. Les données sont basées sur des méta-analyses de 7 essais comparatifs contrôlés randomisés chez 439 participants. Adapté de [33].

Pris ensemble, les preuves issues des essais contrôlés randomisés individuels et des revues systématiques et méta-analyses des essais contrôlés randomisés ont contribue à la reconnaissance généralisée des avantages du régime Portfolio dans les principales directives internationales de pratique clinique pour le cœur et le diabète. Il s’agit notamment des directives de pratique clinique de Canadian Cardiovascular Society (CCS) [35], de Diabetes Canada [36], de Heart UK [37], de Heart Foundation of Australia [38], de American College of Cardiology/American Heart Association [39] et de European Atherosclerosis Society (EAS) [40] (Tableau 1), tandis que chacun des composants alimentaires a été reconnu pour sa capacité à réduire le taux de LDL-C par le groupe de travail conjoint de European Society of Cardiology (ESC) et EAS [41].

Pour faciliter la mise en œuvre du régime Portfolio dans la pratique clinique, notre équipe a mis au point un certain nombre d’outils d’engagement des patients et des médecins, qui sont une traduction directe des directives de pratique clinique. Tout d’abord, une infographie sur le régime Portfolio (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 Identifier, NCT02481466).

Tableau 1 Directives internationales de pratique clinique pour le cœur et le diabète soutenant le régime Portfolio pour la réduction du risque de LDL-C et de maladies cardiovasculaires athérosclérotique (ASCVD ) [35-40].

Association pour le cœur ou le diabète

Conseils

Liens utiles du Canadian Cardiovascular Society :

Pour des ressources complémentaires, cliquez ici.

Pour l’infographie sur le régime Portfolio, cliquez ici.

Diabetes Canada GuidelinesDownload

2021 Canadian Cardiovascular Society Guidelines for DyslipidemiaDownload

Références

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