The portfolio dietary pattern and risk of cardiovascular disease mortality during 1988-2019 in US adults: a prospective cohort study

Meaghan E Kavanagh^{1

2}, Andreea Zurbau^{1

2}, Andrea J Glenn^{1

2

3

4}, Julianah O Oguntala^{1

2

5}, Robert G Josse⁶, Vasanti S Malik^{1

3

7}, Laura Chiavaroli^{1

2

8}, Simin Liu^{9

10

11}, Cyril W C Kendall^{1

2

12}, David J A Jenkins^{1

2

5

6

8}, John L Sievenpiper^{13

14

15

16

17}

Affiliations

¹ Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
² Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Center, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
³ Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
⁴ Department of Nutrition and Food Studies, New York University, New York, NY, USA.
⁵ Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁶ Division of Endocrinology and Metabolism, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
⁷ Joannah & Brian Lawson Centre for Child Nutrition, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁸ Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
⁹ Department of Epidemiology & Biostatistics, Joe C. Wen School of Population and Public Health, University of California, Irvine, CA, USA.
¹⁰ Center for Global Cardiometabolic Health & Nutrition, University of California, Irvine, CA, USA.
¹¹ Division of Cardiology, Department of Medicine, UC Irvine School of Medicine, Irvine, CA, USA.
¹² College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada.
¹³ Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.
¹⁴ Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Center, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.
¹⁵ Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.
¹⁶ Division of Endocrinology and Metabolism, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.
¹⁷ Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.

PMID: 40394599
PMCID: PMC12093672
DOI: 10.1186/s12916-025-04067-1

The portfolio dietary pattern and risk of cardiovascular disease mortality during 1988-2019 in US adults: a prospective cohort study

Meaghan E Kavanagh et al. BMC Med. 2025.

. 2025 May 21;23(1):287.

doi: 10.1186/s12916-025-04067-1.

Authors

Affiliations

¹ Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
² Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Center, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
³ Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
⁴ Department of Nutrition and Food Studies, New York University, New York, NY, USA.
⁵ Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁶ Division of Endocrinology and Metabolism, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
⁷ Joannah & Brian Lawson Centre for Child Nutrition, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁸ Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
⁹ Department of Epidemiology & Biostatistics, Joe C. Wen School of Population and Public Health, University of California, Irvine, CA, USA.
¹⁰ Center for Global Cardiometabolic Health & Nutrition, University of California, Irvine, CA, USA.
¹¹ Division of Cardiology, Department of Medicine, UC Irvine School of Medicine, Irvine, CA, USA.
¹² College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada.
¹³ Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.
¹⁴ Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Center, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.
¹⁵ Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.
¹⁶ Division of Endocrinology and Metabolism, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.
¹⁷ Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.

PMID: 40394599
PMCID: PMC12093672
DOI: 10.1186/s12916-025-04067-1

Abstract

Background: The Portfolio Diet, a dietary pattern of cholesterol-lowering foods, has been shown to reduce cardiovascular disease (CVD) risk factors in clinical trials and lower CVD risk in observational cohorts of mainly white men and women. However, evidence on mortality outcomes in diverse populations is limited.

Objective: To examine the association of the Portfolio dietary pattern with CVD mortality in a racially diverse cohort.

Methods: A total of 14,835 US adults from the National Health and Nutrition Examination Survey, NHANES (1988-1994), were included. Diet was assessed by a 24-h dietary recall which was supplemented with a food frequency questionnaire at baseline using the Portfolio Diet Score (PDS), with positive points for nuts, plant protein, viscous fiber, phytosterols, and plant monounsaturated fatty acid sources, and negative points for foods high in saturated fat and cholesterol (range, 6-30 points). The primary outcome was CVD mortality. Other mortality outcomes included coronary heart disease (CHD), stroke, and all-cause mortality.

Results: During 22 years of follow-up, 2300 CVD deaths, including 1887 CHD deaths, 413 stroke deaths, and 6238 all-cause deaths were documented. Greater adherence was inversely associated with risk factors including blood lipids, glycemia, and inflammation. Treated as a continuous variable, an increase in PDS by 8 points was associated with a 12% (hazard ratio 0.88 [95% confidence intervals:0.78, 0.99]), 14% (0.86 [0.78, 0.96]), and 12% (0.88 [0.82, 0.95]) lower risk of CVD, CHD, and all-cause mortality after adjustments for known CVD risk factors. Comparing the highest to lowest tertiles of the PDS, higher PDS was associated with 16% (0.84 [0.73, 0.98]), 18% (0.82 [0.72, 0.95]) and 14% (0.86 [0.78, 0.96]) lower risk of CVD, CHD, and all-cause mortality, respectively. As part of exploratory analyses, an interaction between PDS and race/ethnicity was observed, emphasizing the necessity of future research involving underserved groups.

Conclusions: Among a national cohort of racially diverse adults in the US, greater adherence to the Portfolio dietary pattern was inversely and prospectively associated with CVD, CHD, and all-cause mortality.

Keywords: All-cause mortality; Cardiovascular disease mortality; Cholesterol reduction; Dietary pattern; Dietary portfolio; Plant-based; Portfolio diet; Prospective cohort study.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: NHANES III received institutional review board approval from the National Center for Health Statistics Research Ethics Review Board (USA CDC, 2015) and required the provision of written informed consent to participate. Consent for publication: Not applicable. Competing interests: AZ is a part-time employee at INQUIS Clinical Research, Ltd., a contract research organization. She has received consulting fees from Glycemic Index Foundation. AJG has received honoraria or travel support from the Good Food Institute, the British Nutrition Society, Vinasoy, and the Academy of Nutrition and Dietetics. VSM is on the Advisory board of the Canadian Institutes of Health Research Institute of Nutrition metabolism and diabetes and is on the Scientific Advisory Committee for Healthy Eating Research at Robert Wood Johnson Foundation for the consensus statement on beverages for children. LC has received research funding from the Canadian Institutes of Health Research (CIHR), Protein Industries Canada (a Government of Canada Global Innovation Cluster), the United Soybean Board (The United States Department of Agriculture Soybean “Check-off” Program) and the Alberta Pulse Growers. She has received honoraria from the Arkansas Children’s Hospital and travel funding from the World Sugars Research Organization for an internal presentation in 2022. 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, White Wave 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, White Wave 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. 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. MEK, JOO, SL, and RGJ report no relevant competing interests.

Figures

**Fig. 1**
Distributions of Portfolio Diet Score (PDS) and adjusted differences in hazard ratio for primary outcome of CVD mortality* using 13.97 as reference value (midpoint of the lowest tertile of PDS), in US adults: National Health and Nutrition Examination Survey Linked Mortality Files (1988–2019). Abbreviations: CI, confidence intervals; CVD, cardiovascular disease; HR, hazard ratio. Cox regression models were used to estimate the adjusted differences in HR of CVD^* and corresponding 95% CI. HRs were coded using restricted cubic spline (RCS) function with three knots located at the 5th, 50th, and 95th percentiles of the PDS distribution (reference value = 13.9, the mean PDS of tertile 1). Solid red line represents HR and dotted lines represent 95% CIs. Estimates were adjusted by age, sex, and race/ethnicity, educational attainment, smoking status, Poverty Income Ratio, marital status, physical activity, alcohol consumption, family history of CVD, self-reported cancer (other than skin), self-reported type-2 diabetes, self-reported hypertension, energy intake, and sodium. *CVD mortality defined as deaths identified as Disease of heart (ICD codes: I00-I09, I11, I13, I20-I51) and Cerebrovascular disease (ICD codes I60-I69)

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The portfolio dietary pattern and risk of cardiovascular disease mortality during 1988-2019 in US adults: a prospective cohort study

Affiliations

The portfolio dietary pattern and risk of cardiovascular disease mortality during 1988-2019 in US adults: a prospective cohort study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Miscellaneous