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The Portfolio diet

This HEART UK Nutrition Academy webpage has been funded by Novartis Pharmaceuticals UK Ltd who have had no input into the content or development of this material.
 

The Portfolio diet is a plant-based diet specifically designed to lower LDL cholesterol. We investigate the evidence underpinning the Portfolio's success.

Take home messages

  • The Portfolio diet is a plant-based eating pattern characterised by a low saturated fat diet with the addition of four specific cholesterol-lowering foods and plant compounds: nuts, soya and legumes, plant sterols, and foods rich in viscous fibres such as oats and beans.
  • Under controlled metabolic conditions, the Portfolio diet has been shown to lower LDL cholesterol by up to 35%.
  • In free-living individuals, it can reduce LDL cholesterol by 17%.
  • Large cohort studies suggest that the Portfolio diet can lower CVD risk by 11-14%.
  • How closely a person follows the diet directly correlates to the degree of LDL cholesterol-lowering.
  • Each of the four cholesterol-lowering foods is capable of achieving a 5-10% reduction in LDL cholesterol. This flexibility allows individuals to adapt the diet at their own pace while still reaping the rewards.

The Portfolio diet, developed by Dr Jenkins and his team at the University of Toronto in the early 2000s, is a plant-based dietary approach specifically designed to reduce low density lipoprotein (LDL) cholesterol1. Their research found that the combination of four foods/plant compounds, known for their cholesterol-lowering properties, brought about a sizeable additive effect on lowering LDL cholesterol. Metabolic studies demonstrated a 35% drop in LDL cholesterol which is comparable to that of first-generation statins1,2.

What is the Portfolio diet?

The Portfolio diet food components1–3

The National Cholesterol Education Programme Step II (NCEPII)4 forms the foundations:

Plus four foods / plant compounds proven to lower blood cholesterol. Quantities given per 2,000kcal intake
  • ≤30% total fat
  • <7% calories from saturated fatty acids (SFA)
  • <200 mg dietary cholesterol daily
  • Protein at 15% energy
  • 20-30g fibres per day

 

  • 42g nuts: tree nuts or peanuts
  • 50g plant proteins: soya and pulses
  • 20g viscous fibres: oats, barley, psyllium, eggplant, okra, apples, oranges and berries
  • 2g phytosterols
  • Later adaptations include 13% carbohydrate replacement with monounsaturated fatty acids (MUFA) – avocados and olive oil.

Each of the four cholesterol-lowering foods/plant compounds have been shown to reduce LDL cholesterol by 5-12%3. The fat profile of the baseline diet – which is very low in saturated fats and includes unsaturated fat – will also contribute to reductions in LDL cholesterol5–7.

What is the evidence?

Impact on LDL cholesterol – randomised controlled trials

  • Jenkins and team conducted four metabolic studies with small numbers (13 to 46) of hyperlipidaemic patients1. Under controlled conditions, a month on the Portfolio diet resulted in a 28% to 35% reduction in LDL cholesterol. This was comparable to first generation statins1,8.
    • In real-life scenarios with free-living hyperlipidaemic individuals, the Portfolio diet showed significant but slightly lower LDL cholesterol reductions.
    • Reductions in LDL cholesterol increased with increasing adherence to the Portfolio diet.
  • In a 12-month study with 66 hyperlipidaemic participants, LDL cholesterol was 14% lower at three months and 12.8% lower at one year9. These correlated with lower CVD risk. Notably, one-third of the participants sustained high adherence over the 12 months, leading to LDL cholesterol reductions of over 20%. 
  • In a 2011 6-month parallel study with 351 hyperlipidaemic subjects, the Portfolio diet (with routine or intensive dietetic input) demonstrated significantly greater LDL cholesterol reductions (−13.8% and −13.1%, respectively) compared to a control low-fat diet (−3.0%)10.
  • In a meta-analysis of seven randomised controlled trials involving 439 hypercholesterolaemic participants, the Portfolio diet resulted in a significant 17% reduction in LDL cholesterol3.
    • Additionally, adherence to the Portfolio diet showed significant improvements in non-HDL cholesterol, apolipoprotein B, total cholesterol, triglycerides, systolic and diastolic blood pressure, C-reactive protein, and estimated 10-year coronary heart disease (CHD) risk when compared to a very low saturated fat control diet (p < 0.05).

Impact on CVD risk – large cohort studies

Given the substantial reduction in LDL cholesterol achieved with the Portfolio diet, its connection to a lower CVD risk is unsurprising considering the now undisputed direct causal correlation between plasma LDL cholesterol and CVD5,11.

Recent publications have assessed adherence to the Portfolio diet and CVD risk in large cohort studies2,12
  • In the Women’s Health Initiative study which included 123,330 post-menopausal women, higher adherence to the Portfolio diet was associated with an 11% lower CVD risk, 14% lower CHD risk, and 17% lower stroke risk compared to the lowest adherence2
  • Similar results were found in a study of over 210,000 US men and women, with highest adherence linked to a 14% lower risk of CVD, CHD, and strokes12. These findings remained consistent after considering confounding factors. 
  • Another publication also identified a 31% reduced risk of type 2 diabetes, a significant metabolic risk factor for CVD, in post-menopausal women adhering to the Portfolio diet13.

In summary

The Portfolio diet is a plant-based dietary approach specifically designed to lower LDL cholesterol. It is based on a very low saturated fat foundation diet with the addition of four specific foods and plant ingredients, each proven to lower blood LDL cholesterol. The combined effect of the low saturated fat content and the four foods has been extensively researched and demonstrated to lower LDL cholesterol by up to 35%.  The LDL cholesterol reduction is directly linked to the degree of adherence.

As well as effectively lowering LDL cholesterol, the Portfolio diet has been found to lower total cholesterol, triglycerides and blood pressure and associated metabolic risk factors of both CVD and CHD.

CPD e-learning Module 4: the four cholesterol-lowering foods

Find out more

References

  1. Jenkins DJA, Josse AR, Wong JMW, Nguyen TH, Kendall CWC. The portfolio diet for cardiovascular risk reduction. Curr Atheroscler Rep. 2007;9(6):501-507. doi:10.1007/s11883-007-0067-7
  2. Glenn AJ, Lo K, Jenkins DJA, et al. Relationship Between a Plant‐Based Dietary Portfolio and Risk of Cardiovascular Disease: Findings From the Women’s Health Initiative Prospective Cohort Study. J Am Heart Assoc. 2021;10(16):e021515. doi:10.1161/JAHA.121.021515
  3. Chiavaroli L, Nishi SK, Khan TA, et al. Portfolio Dietary Pattern and Cardiovascular Disease: A Systematic Review and Meta-analysis of Controlled Trials. Progress in Cardiovascular Diseases. 2018;61(1):43-53. doi:10.1016/j.pcad.2018.05.004
  4. Expert Panel on Detection E and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-2497. doi:10.1001/jama.285.19.2486
  5. Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice: Developed by the Task Force for cardiovascular disease prevention in clinical practice with representatives of the European Society of Cardiology and 12 medical societies With the special contribution of the European Association of Preventive Cardiology (EAPC). European Heart Journal. 2021;42(34):3227-3337. doi:10.1093/eurheartj/ehab484
  6. SACN. Saturated fats and health. GOV.UK. Published August 2019. Accessed October 16, 2023. https://www.gov.uk/government/publications/saturated-fats-and-health-sacn-report
  7. Li Y, Hruby A, Bernstein AM, et al. Saturated Fats Compared With Unsaturated Fats and Sources of Carbohydrates in Relation to Risk of Coronary Heart Disease: A Prospective Cohort Study. Journal of the American College of Cardiology. 2015;66(14):1538-1548. doi:10.1016/j.jacc.2015.07.055
  8. Gigleux I, Jenkins DJA, Kendall CWC, et al. Comparison of a dietary portfolio diet of cholesterol-lowering foods and a statin on LDL particle size phenotype in hypercholesterolaemic participants. Br J Nutr. 2007;98(6):1229-1236. doi:10.1017/S0007114507781461
  9. Jenkins DJA, Kendall CWC, Faulkner DA, et al. Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia. Am J Clin Nutr. 2006;83(3):582-591. doi:10.1093/ajcn.83.3.582
  10. Jenkins DJA, Jones PJH, Lamarche B, et al. 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(8):831-839. doi:10.1001/jama.2011.1202
  11. 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. European Heart Journal. 2017;38(32):2459-2472. doi:10.1093/eurheartj/ehx144
  12. Glenn AJ, Guasch-Ferré M, Malik VS, et al. Portfolio Diet Score and Risk of Cardiovascular Disease: Findings From 3 Prospective Cohort Studies. Circulation. 2023;148(22):1750-1763. doi:10.1161/CIRCULATIONAHA.123.065551
  13. Glenn AJ, Li J, Lo K, et al. The Portfolio Diet and Incident Type 2 Diabetes: Findings From the Women’s Health Initiative Prospective Cohort Study. Diabetes Care. 2023;46(1):28-37. doi:10.2337/dc22-1029

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