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. 2025 May 13;25(1):1761.
doi: 10.1186/s12889-025-22479-9.

Portfolio diet and LDL-C in a young, multiethnic cohort: cross-sectional analyses with cumulative exposure modeling

Victoria Chen  1   2 , Laura Chiavaroli  1   2   3 , Andrea J Glenn  4   5 , Meaghan E Kavanagh  1   2 , Tara Zeitoun  1 , Sara Mahdavi  1   4 , Cyril W C Kendall  1   2   6 , David J A Jenkins  1   2   7   8   3 , Ahmed El-Sohemy  1 , John L Sievenpiper  9   10   11   12   13
Affiliations

Portfolio diet and LDL-C in a young, multiethnic cohort: cross-sectional analyses with cumulative exposure modeling

Victoria Chen et al. BMC Public Health. .

Abstract

Background: The Portfolio Diet is a plant-based dietary pattern of cholesterol-lowering foods that has demonstrated clinically meaningful reductions in low-density lipoprotein cholesterol (LDL-C) and other cardiovascular risk factors. However, the Portfolio Diet has not been assessed in an ethnoculturally diverse population of young adults.

Objective: To examine the association of the Portfolio Diet Score (PDS) with LDL-C and other established cardiovascular risk factors in a young adult population.

Methods: This cross-sectional analysis included 1,507 men and women (mean age, 23 ± 3 years) of diverse ethnocultural backgrounds from the Toronto Nutrigenomics and Health Study. Diet was assessed by a validated Toronto-modified Harvard 196-item food frequency questionnaire with adherence to the Portfolio Diet measured using the Portfolio Diet Score. Data were analyzed using multiple linear regressions with adjustment for potential confounders. Modeling analyses related LDL-C levels according to absolute adherence to the Portfolio Diet with cumulative LDL-C and onset of rising cardiovascular risk by age.

Results: Participants were Caucasian (49%), East Asian (34%), South Asian (11%), or other (7%) with a mean LDL-C of 2.3 ± 0.7mmol/L. A 1-point higher PDS and higher PDS tertiles were associated with lower LDL-C (ß [95% CI] per 1-point: -0.009mmol/L [-0.016, -0.002], P = 0.013; Ptrend across tertiles =0.040), non-HDL-C (-0.010mmol/L [-0.018, -0.002], P = 0.014; Ptrend=0.028), total cholesterol (-0.011mmol/L [-0.019, -0.003], P = 0.011; Ptrend=0.038), systolic blood pressure (-0.150mmHg [-0.250, -0.050], P = 0.003; Ptrend<0.001) and diastolic blood pressure (-0.133mmHg [-0.219, -0.046], P = 0.003; Ptrend<0.001). Higher PDS tertiles were associated with lower triglycerides (Ptrend=0.039). A 1-point higher PDS was also associated with lower BMI (-0.038 kg/m2 [-0.071, -0.004], P = 0.026), waist circumference (-0.092cm [-0.171, -0.013], P = 0.022), body weight (-0.124 kg [-0.229, -0.019], P = 0.021) and FMI (-0.019 kg/m2 [-0.037, -0.001], P =0.039). There was no association with HDL-C, CRP, or fasting glucose. Modeling analyses suggest that compared to low adherence, 50% and 100% adherence to the Portfolio Diet may delay the onset of rising cardiovascular risk by an estimated 6 and 13 years, respectively.

Conclusions: Among young adults, the PDS was inversely associated with LDL-C and several other established cardiovascular risk factors. Early adherence to the Portfolio Diet may limit lifetime exposure to LDL-C and could delay the age at which cardiovascular events begin.

Keywords: Cardiovascular risk factors; Cumulative exposure; LDL-C; Portfolio Diet; Primordial prevention; Young adults.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Research Ethics Board at the University of Toronto and written informed consent was obtained from all participants. Consent for publication: Not applicable. Competing interests: LC has received research support from the Canadian Institutes of Health Research (CIHR), Protein Industries Canada (a Government of Canada Global Innovation Clusters), The United Soybean Board (USDA soy “Checkoff” program), and the Alberta Pulse Growers Association. AJG has received honoraria or travel support from the British Nutrition Society, Vinasoy, and the Good Food Institute. SM has received funding for advisory board activities, consulting roles, educational grants, travel grants, and speaker/moderator honoraria from the American Academy of Nutrition, World Congress of Aesthetics and Anti-Aging Medicine, Canadian Board of Aesthetic Medicine, Canadian Association of Medical Aesthetics, Canadian Association of Aesthetic Medicine, Los Angeles Multi-Specialty Cosmetic Academy, Allergan, Galderma, Sanofi, Shire, Genzyme, Gambro, Nutrigenomix, and Abbott. SM has received fellowship, educational, and research funding from Harvard University, the University of Toronto, and Mitacs. SM has provided in-kind educational speaker services to the University of Miami Dermatology Department and has served on the Editorial Board of the Canadian Journal of Kidney Disease and Health, the official journal of the Canadian Society of Nephrology. SM is an associate editor of the Canadian Journal of Kidney Disease and Health and an assistant editor of BMJ Nutrition, Prevention & Health. CWCK has received grants or research support from the Advanced Food Materials Network, Agriculture and Agri-Foods Canada (AAFC), Almond Board of California, Barilla, Canadian Institutes of Health Research (CIHR), Canola Council of Canada, International Nut and Dried Fruit Council, International Tree Nut Council Research and Education Foundation, Loblaw Brands Ltd, the Peanut Institute, Pulse Canada and Unilever. He has received in-kind research support from the Almond Board of California, Barilla, California Walnut Commission, Kellogg Canada, Loblaw Companies, Nutrartis, Quaker (PepsiCo), the Peanut Institute, Primo, Unico, Unilever, WhiteWave Foods/Danone. He has received travel support and/or honoraria from the Barilla, California Walnut Commission, Canola Council of Canada, General Mills, International Nut and Dried Fruit Council, International Pasta Organization, Lantmannen, Loblaw Brands Ltd, Nutrition Foundation of Italy, Oldways Preservation Trust, Paramount Farms, the Peanut Institute, Pulse Canada, Sun-Maid, Tate & Lyle, Unilever and White Wave Foods/Danone. He has served on the scientific advisory board for the International Tree Nut Council, International Pasta Organization, McCormick Science Institute and Oldways Preservation Trust. He is a founding member of the International Carbohydrate Quality Consortium (ICQC), Executive Board Member of the Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD), is on the Clinical Practice Guidelines Expert Committee for Nutrition Therapy of the EASD and is a Director of the Toronto 3D Knowledge Synthesis and Clinical Trials foundation. DJAJ has received research grants from Loblaw Companies Ltd., the Almond Board of California, Soy Nutrition Institute (SNI), and the Canadian Institutes of Health Research (CIHR). He has received in-kind supplies for trials as a research support from the Almond board of California, Walnut Council of California, American Peanut Council, Barilla, Unilever, Unico, Primo, Loblaw Companies, Quaker (Pepsico), Pristine Gourmet, Bunge Limited, Kellogg Canada, WhiteWave Foods. He has been on the speaker’s panel, served on the scientific advisory board and/or received travel support and/or honoraria from the Lawson Centre Nutrition Digital Series, 19th Annual Stare-Hegsted Lecture, 2024 Diabetes Canada Conference, Nutritional Fundamentals for Health (NFH)-Nutramedica, Saint Barnabas Medical Center, The University of Chicago, 2020 China Glycemic Index (GI) International Conference, Atlantic Pain Conference, Academy of Life Long Learning, the Almond Board of California, Canadian Agriculture Policy Institute, the Loblaw Companies Ltd, the Griffin Hospital (for the development of the NuVal scoring system), the Coca-Cola Company, Epicure, Danone, Diet Quality Photo Navigation (DQPN), Better Therapeutics (FareWell), Verywell, True Health Initiative (THI), Heali AI Corp, Institute of Food Technologists (IFT), Soy Nutrition Institute (SNI), Herbalife Nutrition Institute (HNI), Herbalife International, Pacific Health Laboratories, Nutritional Fundamentals for Health (NFH), the Soy Foods Association of North America, the Nutrition Foundation of Italy (NFI), the Toronto Knowledge Translation Group (St. Michael’s Hospital), the Canadian College of Naturopathic Medicine, The Hospital for Sick Children, the Canadian Nutrition Society (CNS), and the American Society of Nutrition (ASN). He is a member of the International Carbohydrate Quality Consortium (ICQC). His wife, Alexandra L Jenkins, is senior scientist of INQUIS Clinical Research Inc. (Clinical Research Organization), his 2 daughters, Wendy Jenkins and Amy Jenkins, have published a vegetarian book that promotes the use of the low glycemic index plant foods advocated here, The Portfolio Diet for Cardiovascular Risk Reduction (Academic Press/Elsevier 2020 ISBN:978-0-12-810510-8) and his sister, Caroline Brydson, received funding through a grant from the St. Michael’s Hospital Foundation to develop a cookbook for one of his studies. AE-S is the founder and holds shares in Nutrigenomix Inc. JLS has received research support from the Canadian Foundation for Innovation, Ontario Research Fund, Province of Ontario Ministry of Research and Innovation and Science, Canadian Institutes of health Research (CIHR), Diabetes Canada, American Society for Nutrition (ASN), National Honey Board (U.S. Department of Agriculture [USDA] honey “Checkoff” program), Institute for the Advancement of Food and Nutrition Sciences (IAFNS), Pulse Canada, Quaker Oats Center of Excellence, INC International Nut and Dried Fruit Council Foundation, The United Soybean Board (USDA soy “Checkoff” program), Protein Industries Canada (a Government of Canada Global Innovation Cluster), Almond Board of California, European Fruit Juice Association, The Tate and Lyle Nutritional Research Fund at the University of Toronto, The Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund at the University of Toronto (a fund established by the Alberta Pulse Growers), The Plant Protein Fund at the University of Toronto (a fund which has received contributions from IFF among other donors), The Plant Milk Fund at the University of Toronto (a fund established by the Karuna Foundation through Vegan Grants), and The Nutrition Trialists Network Fund at the University of Toronto (a fund established by donations from the Calorie Control Council, Physicians Committee for Responsible Medicine, and Login5 Foundation). He has received food donations to support randomized controlled trials from the Almond Board of California, California Walnut Commission, Danone, Nutrartis, Soylent, and Dairy Farmers of Canada. He has received travel support, speaker fees and/or honoraria from FoodMinds LLC, Nestlé, Abbott, General Mills, Nutrition Communications, International Food Information Council (IFIC), Arab Beverage Association, International Sweeteners Association, Calorie Control Council, Phynova, and Collaborative CME and Research Network (CCRN). He has or has had ad hoc consulting arrangements with Almond Board of California, Perkins Coie LLP, Tate & Lyle, Ingredion, and Brightseed. He is on the Clinical Practice Guidelines Expert Committees of Diabetes Canada, European Association for the study of Diabetes (EASD), Canadian Cardiovascular Society (CCS), and Obesity Canada/Canadian Association of Bariatric Physicians and Surgeons. He serves as an unpaid member of the Board of Trustees of IAFNS. He is a Director at Large of the Canadian Nutrition Society (CNS), founding member of the International Carbohydrate Quality Consortium (ICQC), Executive Board Member of the Diabetes and Nutrition Study Group (DNSG) of the EASD, and Director of the Toronto 3D Knowledge Synthesis and Clinical Trials foundation. His spouse is a former employee of Nestle Health Science and AB InBev. VC, MEK and TZ report no relevant competing interests.

Figures

Fig. 1
Fig. 1
Absolute adherence to Portfolio Diet recommendations according to tertiles of the Portfolio Diet Score. Food items on the FFQ in each Portfolio Diet pillar were converted to g/day of plant protein, viscous fibre, nuts, phytosterols and MUFAs and compared to Portfolio Diet recommendations to assess absolute adherence in each tertile of the Portfolio Diet Score (PDS). Adherence was based on established Portfolio Diet recommendations (50g/day plant protein, 20g/day viscous fibre, 45g/day nuts, 2g/day phytosterols and 45g/day MUFAs). Absolute adherence to recommendations is presented as percentage adherence on the y-axis. Absolute adherence according to the clinical-Portfolio Diet Score (c-PDS) score is shown above each bar. The c-PDS score gives 0 to 5 points for each component, yielding a total c-PDS between 0 and 25. The white, grey and black bars represent adherence in tertile 1, 2 and 3, respectively. T1 (low), T2 (mid), and T3 (highest) tertiles of adherence to the Portfolio dietary pattern measured using the PDS. c-PDS, clinical-Portfolio Diet Score; MUFAs, monounsaturated fatty acids; T, tertile
Fig. 2
Fig. 2
Cumulative LDL-C exposure, plaque burden and onset of cardiovascular risk by age according to absolute adherence to the Portfolio Diet. Absolute adherence was related to unadjusted marginal mean LDL-C levels in each PDS tertile determined in our main analysis. LDL-C at other levels of adherence was estimated linearly. The solid black lines represents tertiles 1, 2 and 3 relating to LDL-C levels of 2.34, 2.29 and 2.24mmol/L throughout life, respectively. The solid blue line represents 50% absolute adherence to Portfolio Diet recommendations relating to an estimated LDL-C level of 2.13mmol/L throughout life. The solid orange line represents 100% absolute adherence to Portfolio Diet recommendation relating to an estimated LDL-C level of 1.89mmol/L throughout life. Cumulative LDL-C exposure was calculated by multiplying LDL-C levels by age. The black dots represent the cumulative LDL-C level at 23 years of age, equal to the mean age of the TNH Study cohort. The red dots represent the average age where cumulative LDL-C reaches 125mmol-years marking the threshold for the onset of exponential myocardial infarction risk increase. Age at which risk of myocardial infarction begins to rise is 55 years for 6% adherence (T1), 61 years for 50% adherence and 68 years for 100% adherence. Modeled using methods from Ference BA et al. J Am Coll Cardiol 2018; 72(10):1141-56 [38]. T1 (low), T2 (mid), and T3 (highest) tertiles of adherence to the Portfolio dietary pattern measured using the Portfolio Diet Score (PDS). c-PDS, clinical-Portfolio Diet Score; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; T, tertile
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