BACKGROUND: The evidence for the Portfolio dietary pattern, a plant-based dietary pattern that combines recognized cholesterol-lowering foods (nuts, plant protein, viscous fibre, plant sterols), has not been summarized. OBJECTIVE: To update the European Association for the Study of Diabetes clinical practice guidelines for nutrition therapy, we conducted a systematic review and meta-analysis of controlled trials using GRADE of the effect of the Portfolio dietary pattern on the primary therapeutic lipid target for cardiovascular disease prevention, low-density lipoprotein cholesterol (LDL-C), and other established cardiometabolic risk factors. METHODS: We searched MEDLINE, EMBASE, and The Cochrane Library through April 19, 2018. We included controlled trials ≥ 3-weeks assessing the effect of the Portfolio dietary pattern on cardiometabolic risk factors compared with an energy-matched control diet free of Portfolio dietary pattern components. Two independent reviewers extracted data and assessed risk of bias. The primary outcome was LDL-C. Data were pooled using the generic inverse-variance method and expressed as mean differences (MDs) with 95% confidence intervals (CIs). Heterogeneity was assessed (Cochran Q statistic) and quantified (I2-statistic). GRADE assessed the certainty of the evidence. RESULTS: Eligibility criteria were met by 7 trial comparisons in 439 participants with hyperlipidemia, in which the Portfolio dietary pattern was given on a background of a National Cholesterol Education Program (NCEP) Step II diet. The combination of a portfolio dietary pattern and NCEP Step II diet significantly reduced the primary outcome LDL-C by ~17% (MD, -0.73 mmol/L, [95% CI, -0.89 to -0.56 mmol/L]) as well as non-high-density lipoprotein cholesterol, apolipoprotein B, total cholesterol, triglycerides, systolic and diastolic blood pressure, C-reactive protein, and estimated 10-year coronary heart disease (CHD) risk, compared with an NCEP Step 2 diet alone (p < 0.05). There was no effect on high-density lipoprotein cholesterol or body weight. The certainty of the evidence was high for LDL-cholesterol and most lipid outcomes and moderate for all others outcomes. CONCLUSIONS: Current evidence demonstrates that the Portfolio dietary pattern leads to clinically meaningful improvements in LDL-C as well as other established cardiometabolic risk factors and estimated 10-year CHD risk.

CIBER Fisiopatología de la Obesidad y Nutrición Instituto de Salud Carlos 3 Madrid Spain; Human Nutrition Department IISPV Universitat Rovira i Virgili Reus Spain

Department of Endocrinology Diabetes and Clinical Pharmacology Dubrava University Hospital Zagreb Croatia

Institute for Clinical and Experimental Medicine Diabetes Centre Prague Czech Republic; Physicians Committee for Responsible Medicine Washington DC USA

Toronto 3D Knowledge Synthesis and Clinical Trials Unit Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto ON Canada; Department of Nutritional Sciences Faculty of Medicine University of Toronto Toronto ON Canada

Toronto 3D Knowledge Synthesis and Clinical Trials Unit Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto ON Canada; Department of Nutritional Sciences Faculty of Medicine University of Toronto Toronto ON Canada; College of Pharmacy and Nutrition University of Saskatchewan Saskatoon SK Canada

Toronto 3D Knowledge Synthesis and Clinical Trials Unit Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto ON Canada; Department of Nutritional Sciences Faculty of Medicine University of Toronto Toronto ON Canada; Department of Medicine Faculty of Medicine University of Toronto Toronto ON Canada; Li Ka Shing Knowledge Institute St Michael's Hospital Toronto ON Canada; Division of Endocrinology and Metabolism St Michael's Hospital Toronto ON Canada

Toronto 3D Knowledge Synthesis and Clinical Trials Unit Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto ON Canada; Department of Nutritional Sciences Faculty of Medicine University of Toronto Toronto ON Canada; Li Ka Shing Knowledge Institute St Michael's Hospital Toronto ON Canada; Division of Endocrinology and Metabolism St Michael's Hospital Toronto ON Canada

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