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.

[1]  D. Rahelić,et al.  Mediterranean diet, cardiovascular disease and mortality in diabetes: A systematic review and meta-analysis of prospective cohort studies and randomized clinical trials , 2020, Critical reviews in food science and nutrition.

[2]  T. Wilt,et al.  Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome , 2020, Annals of Internal Medicine.

[3]  J. Manson,et al.  Olive Oil Consumption and Cardiovascular Risk in U.S. Adults. , 2020, Journal of the American College of Cardiology.

[4]  L. Iacoviello,et al.  Associations between Dietary Pulses Alone or with Other Legumes and Cardiometabolic Disease Outcomes: An Umbrella Review and Updated Systematic Review and Meta-analysis of Prospective Cohort Studies , 2019, Advances in nutrition.

[5]  D. Rahelić,et al.  Relation of Vegetarian Dietary Patterns With Major Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Prospective Cohort Studies , 2019, Front. Nutr..

[6]  D. Rahelić,et al.  DASH Dietary Pattern and Cardiometabolic Outcomes: An Umbrella Review of Systematic Reviews and Meta-Analyses , 2019, Nutrients.

[7]  M. Hernán,et al.  Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra‐Virgin Olive Oil or Nuts , 2018, The New England journal of medicine.

[8]  D. Rahelić,et al.  Portfolio Dietary Pattern and Cardiovascular Disease: A Systematic Review and Meta-analysis of Controlled Trials. , 2018, Progress in cardiovascular diseases.

[9]  G. Giannelli,et al.  Dietary fiber and health outcomes: an umbrella review of systematic reviews and meta-analyses. , 2018, The American journal of clinical nutrition.

[10]  C. Cannon,et al.  Reduction of low density lipoprotein-cholesterol and cardiovascular events with proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors and statins: an analysis of FOURIER, SPIRE, and the Cholesterol Treatment Trialists Collaboration , 2017, European heart journal.

[11]  Lale Tokgözoğlu,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 , 2017, European heart journal.

[12]  G. Francis,et al.  2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. , 2016, The Canadian journal of cardiology.

[13]  J. Boer,et al.  Diet Quality Scores and Prediction of All-Cause, Cardiovascular and Cancer Mortality in a Pan-European Cohort Study , 2016, PloS one.

[14]  Lawrence A Leiter,et al.  Effect of Replacing Animal Protein with Plant Protein on Glycemic Control in Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials , 2015, Nutrients.

[15]  D. Meyre,et al.  A systematic review and meta-analysis of nut consumption and incident risk of CVD and all-cause mortality , 2015, British Journal of Nutrition.

[16]  Y. T. van der Schouw,et al.  Intake of phytosterols from natural sources and risk of cardiovascular disease in the European Prospective Investigation into Cancer and Nutrition-the Netherlands (EPIC-NL) population , 2015, European journal of preventive cardiology.

[17]  Lawrence A Leiter,et al.  Statin-associated muscle symptoms: impact on statin therapy—European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management , 2015, European heart journal.

[18]  Nancy Xiaonan Yu,et al.  Intake patterns and dietary associations of soya protein consumption in adults and children in the Canadian Community Health Survey, Cycle 2.2. , 2015, The British journal of nutrition.

[19]  D. Tilman,et al.  Global diets link environmental sustainability and human health , 2014, Nature.

[20]  H. Harwatt,et al.  The environmental cost of protein food choices , 2014, Public Health Nutrition.

[21]  L. Schwingshackl,et al.  Monounsaturated fatty acids, olive oil and health status: a systematic review and meta-analysis of cohort studies , 2014, Lipids in Health and Disease.

[22]  JoAnn E Manson,et al.  Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women's Health Initiative Observational Study: evidence to inform national dietary guidance. , 2014, American journal of epidemiology.

[23]  Lawrence A Leiter,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. , 2011, JAMA.

[24]  B. Howard,et al.  Diet quality and the risk of cardiovascular disease: the Women's Health Initiative (WHI). , 2011, The American journal of clinical nutrition.

[25]  Robin Thomas,et al.  Challenges and results of sampling Chinese restaurant menu items for the USDA National Nutrient Database for Standard Reference , 2011 .

[26]  J. Manson,et al.  Physical Activity and Survival in Postmenopausal Women with Breast Cancer: Results from the Women's Health Initiative , 2011, Cancer Prevention Research.

[27]  Lawrence A Leiter,et al.  Adding monounsaturated fatty acids to a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia , 2010, Canadian Medical Association Journal.

[28]  S. Yusuf,et al.  Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study , 2010, The Lancet.

[29]  L. Ellegård,et al.  Food sources of plant sterols in the EPIC Norfolk population , 2008, European Journal of Clinical Nutrition.

[30]  Jennifer G. Robinson,et al.  Validity of diabetes self-reports in the Women's Health Initiative: comparison with medication inventories and fasting glucose measurements , 2008, Clinical trials.

[31]  L. Ellegård,et al.  Inverse relation between dietary intake of naturally occurring plant sterols and serum cholesterol in northern Sweden. , 2008, The American journal of clinical nutrition.

[32]  Katie J. Ward,et al.  Health, ethics and environment: A qualitative study of vegetarian motivations , 2008, Appetite.

[33]  Samia Mora,et al.  Blood pressure and risk of developing type 2 diabetes mellitus: the Women's Health Study. , 2007, European heart journal.

[34]  S. van Buuren Multiple imputation of discrete and continuous data by fully conditional specification , 2007, Statistical methods in medical research.

[35]  L. Ellegård,et al.  A phytosterol database: Fatty foods consumed in Sweden and the Netherlands☆ , 2007 .

[36]  F. Saura-calixto,et al.  Common sources and estimated intake of plant sterols in the Spanish diet. , 2006, Journal of agricultural and food chemistry.

[37]  Lawrence A Leiter,et al.  Assessment of the Longer Term Effects of a Dietary Portfolio of Cholesterol Lowering Foods in Hypercholesterolemia , 2006, The American journal of clinical nutrition.

[38]  K. Phillips,et al.  Phytosterol composition of nuts and seeds commonly consumed in the United States. , 2005, Journal of agricultural and food chemistry.

[39]  C. Kooperberg,et al.  Comparison of self-report, hospital discharge codes, and adjudication of cardiovascular events in the Women's Health Initiative. , 2004, American journal of epidemiology.

[40]  Lawrence A Leiter,et al.  The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia. , 2003, Metabolism: clinical and experimental.

[41]  R. Langer,et al.  The Women's Health Initiative Observational Study: baseline characteristics of participants and reliability of baseline measures. , 2003, Annals of epidemiology.

[42]  Garnet L Anderson,et al.  The Women's Health Initiative recruitment methods and results. , 2003, Annals of epidemiology.

[43]  C. Kooperberg,et al.  Outcomes ascertainment and adjudication methods in the Women's Health Initiative. , 2003, Annals of epidemiology.

[44]  Lawrence A Leiter,et al.  Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. , 2003, JAMA.

[45]  Lawrence A Leiter,et al.  A dietary portfolio approach to cholesterol reduction: combined effects of plant sterols, vegetable proteins, and viscous fibers in hypercholesterolemia. , 2002, Metabolism: clinical and experimental.

[46]  Susanne Bryngelsson,et al.  The Phytosterol Content of Some Cereal Foods Commonly Consumed in Sweden and in the Netherlands , 2002 .

[47]  P. Corey,et al.  Effect of a very-high-fiber vegetable, fruit, and nut diet on serum lipids and colonic function. , 2001, Metabolism: clinical and experimental.

[48]  A. Kristal,et al.  Measurement characteristics of the Women's Health Initiative food frequency questionnaire. , 1999, Annals of epidemiology.

[49]  P. Wolf,et al.  Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. , 1991, Stroke.

[50]  I M Buzzard,et al.  Sources of data for developing and maintaining a nutrient database. , 1988, Journal of the American Dietetic Association.

[51]  G Block,et al.  A data-based approach to diet questionnaire design and testing. , 1986, American journal of epidemiology.

[52]  Catherine B. Chan,et al.  Nutrition Therapy. , 2018, Canadian journal of diabetes.

[53]  R. Krauss,et al.  Low-density lipoproteins cause atherosclerotic cardiovascular disease , 2018 .

[54]  J. Mckenney,et al.  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). , 2001, JAMA.

[55]  P. Renshaw,et al.  [Detection, evaluation, and treatment of high blood cholesterol in adults]. , 2001, Revista panamericana de salud publica = Pan American journal of public health.