Relationship Between a Plant‐Based Dietary Portfolio and Risk of Cardiovascular Disease: Findings From the Women's Health Initiative Prospective Cohort Study

Background The plant‐based Dietary Portfolio combines established cholesterol‐lowering foods (plant protein, nuts, viscous fiber, and phytosterols), plus monounsaturated fat, and has been shown to improve low‐density lipoprotein cholesterol and other cardiovascular disease (CVD) risk factors. No studies have evaluated the relation of the Dietary Portfolio with incident CVD events. Methods and Results We followed 123 330 postmenopausal women initially free of CVD in the Women's Health Initiative from 1993 through 2017. We used Cox proportional‐hazard models to estimate adjusted hazard ratios (HRs) and 95% CI of the association of adherence to a Portfolio Diet score with CVD outcomes. Primary outcomes were total CVD, coronary heart disease, and stroke. Secondary outcomes were heart failure and atrial fibrillation. Over a mean follow‐up of 15.3 years, 13 365 total CVD, 5640 coronary heart disease, 4440 strokes, 1907 heart failure, and 929 atrial fibrillation events occurred. After multiple adjustments, adherence to the Portfolio Diet score was associated with lower risk of total CVD (HR, 0.89; 95% CI, 0.83–0.94), coronary heart disease (HR, 0.86; 95% CI, 0.78–0.95), and heart failure (HR, 0.83; 95% CI, 0.71–0.99), comparing the highest to lowest quartile of adherence. There was no association with stroke (HR, 0.97; 95% CI, 0.87–1.08) or atrial fibrillation (HR, 1.10; 95% CI, 0.87–1.38). These results remained statistically significant after several sensitivity analyses. Conclusions In this prospective cohort of postmenopausal women in the United States, higher adherence to the Portfolio Diet was associated with a reduction in incident cardiovascular and coronary events, as well as heart failure. These findings warrant further investigation in other populations.

Abstract P511: Adherence to the Dietary Portfolio is Associated With Lower Cardiovascular Disease Risk in the Women's Health Initiative Study

Introduction: The Dietary Portfolio is a plant-based dietary pattern of a combination of recognized cholesterol-lowering foods and has been shown to lower a number of cardiovascular disease (CVD) risk factors, including low-density lipoprotein cholesterol, blood pressure and C-reactive protein. However, no studies have assessed if following the Portfolio results in fewer CVD events. Hypothesis: Higher adherence to the Portfolio will be associated with fewer CVD events. Methods: We included 125,389 postmenopausal women from the Women’s Health Initiative Observational Study and Clinical Trials (from 1993 to 2017) who were free of CVD at baseline. Adherence to the Portfolio was assessed using an a priori diet index based on 6 food categories (high in plant protein [soy & pulses], nuts, viscous fiber, plant sterols and monounsaturated fat, and low in saturated fat) that were found to lower CVD risk factors in the Portfolio trials. Adjusted hazard ratios (HRs) and 95% confidence intervals [CIs] for CVD were calculated using Cox regressions. We adjusted for CVD risk & lifestyle factors and potential confounders (see Table 1). Results: During 1,826,176 person-years of follow-up, we documented 11,370 total CVD cases, including 5,739 coronary heart disease (CHD) cases, 4,451 stroke cases, 1,946 heart failure (HF) cases and 935 atrial fibrillation (AF) cases. Comparing the highest to the lowest quartile in the fully adjusted model, higher adherence to the Portfolio was associated with a reduced risk of total CVD (HR=0.89 [95% CI 0.84-0.95]), CHD (0.87 [0.79-0.95]) and HF (0.83 [0.70-0.98]). No association was found with stroke (0.97 [0.87-1.08]) and AF (1.09 [0.87-1.38]). Conclusions: In postmenopausal women, higher adherence to the Portfolio was inversely associated with total CVD, CHD and HF but not stroke or AF. These findings suggest that the Portfolio may assist with CVD, CHD and HF prevention and warrants further investigation. Table 1: Association of the Dietary Portfolio and risk of CVD in Postmenopausal Women

Adding MUFA to a dietary portfolio of cholesterol-lowering foods reduces apoAI fractional catabolic rate in subjects with dyslipidaemia

The present randomised parallel study assessed the impact of adding MUFA to a dietary portfolio of cholesterol-lowering foods on the intravascular kinetics of apoAI- and apoB-containing lipoproteins in subjects with dyslipidaemia. A sample of sixteen men and postmenopausal women consumed a run-in stabilisation diet for 4 weeks. Subjects were then randomly assigned to an experimental dietary portfolio either high or low in MUFA for another 4 weeks. MUFA substituted 13·0 % of total energy from carbohydrate (CHO) in the high-MUFA dietary portfolio. Lipoprotein kinetics were assessed after the run-in and portfolio diets using a primed, constant infusion of [2H3]leucine and multicompartmental modelling. The high-MUFA dietary portfolio resulted in higher apoAI pool size (PS) compared with the low-MUFA dietary portfolio (15·9 % between-diet difference, P= 0·03). This difference appeared to be mainly attributable to a reduction in apoAI fractional catabolic rate (FCR) after the high-MUFA diet ( − 5·6 %, P= 0·02 v. pre-diet values), with no significant change in production rate. The high-MUFA dietary portfolio tended to reduce LDL apoB100 PS compared with the low-MUFA dietary portfolio ( − 28·5 % between-diet difference, P= 0·09), predominantly through an increase in LDL apoB100 FCR (23·2 % between-diet difference, P= 0·04). These data suggest that adding MUFA to a dietary portfolio of cholesterol-lowering foods provides the added advantage of raising HDL primarily through a reduction in HDL clearance rate. Replacing CHO with MUFA in a dietary portfolio may also lead to reductions in LDL apoB100 concentrations primarily by increasing LDL clearance rate, thus potentiating further the well-known cholesterol-lowering effect of this diet.