Cholesterol-friendly diet
Evidence-based foods to prioritise and limit. The Mediterranean-Nordic hybrid pattern has the strongest cardiovascular trial data.
"But I don't eat much sugar" — how everyday carbs become sugar in your blood
Most people picture sugar as the white stuff in fizzy drinks and sweets. But your gut breaks starch — bread, rice, pasta, cereal, potatoes — down into glucose within minutes, and that glucose hits your bloodstream just like table sugar does. The clearest way to see it is each food's glycaemic load (GL): how much a normal portion actually raises your blood glucose. As a rule of thumb, 10 or under is low, 11–19 is medium, and 20 or more is high for a single food.
| Food (typical portion) | Blood-glucose impact (glycaemic load) | GL |
|---|---|---|
| White rice, boiled150g / 1 cup | 33High | |
| Baked potato, large~180g | 31High | |
| Basmati rice, boiled150g | 26High | |
| White pasta (wheat)180g cooked | 24High | |
| Chips / fries150g | 22High | |
| Can of cola330ml — the obvious one | 22High | |
| Cornflakes30g bowl | 21High | |
| Brown rice, boiled150g | 21High | |
| Sweet potato, baked150g | 17Med | |
| Porridge oats, cooked40g dry | 13Med | |
| Banana, ripe1 medium | 12Med | |
| White bread1 slice | 11Med | |
| Sourdough bread1 slice | 8Low | |
| Lentils, cooked150g | 6Low | |
| Apple1 medium | 6Low | |
| Berries (straw/rasp)100g | 2Low | |
| Broccoli / leafy greensany normal portion | 1Low |
In plain teaspoons of sugar: a handy translation (Dr David Unwin's NICE-endorsed method, J. Insulin Resistance 2016) divides a food's glycaemic load by about 2.6. So a can of cola (GL ≈ 22) comes out at roughly 9 teaspoons of sugar and a milk chocolate bar (GL ≈ 16) about 6 — yet a bowl of white rice works out near 13. The starch isn't sugar, but once digested your body treats it almost the same.
Two things should jump out. First, "brown" or "wholemeal" is only marginally better than white in pure blood-glucose terms — the fibre helps the shape of the curve, not the total load by much. Second, several everyday "savoury, sensible" meals — a portion of rice, a baked potato, a plate of pasta, a sandwich — hit your blood sugar as hard as a can of cola you'd never dream of calling healthy. This is the realisation most people are missing, and it's exactly why "I eat pretty well" so often doesn't match what's happening on the inside.
For scale: all of the glucose circulating in your entire 5 litres of blood at any moment is only about 4–5 grams — roughly one teaspoon. A bowl of rice delivers ten times that to be dealt with. That is the load your pancreas has to clear, meal after meal, and why refined-carb portions matter so much more than most people assume.
Read this fairly — what the chart does and doesn't say
This is a measure of blood-glucose impact (glycaemic load), not literal sugar content — a potato contains no sucrose. It tells you how much these foods behave like sugar once digested. Three caveats: (1) whole foods eaten with fibre, protein and fat produce a slower, lower curve than the same teaspoons of pure sugar, and they bring nutrients sugar doesn't — this is about portion and refinement, not a claim that rice "is" sweets; (2) the glycaemic index is a population average and your own response can differ substantially — which is precisely what a short CGM trial (Section 9) reveals; and (3) the same starch is far gentler if you blunt the spike — eat protein and vegetables before the carbs, add olive oil or vinegar, cook-and-cool starchy foods to form resistant starch, and walk for 10–15 minutes afterwards (see the meal-sequencing and CGM modification tips in Section 9). The takeaway isn't "never eat these" — it's smaller portions, less refined versions, and never on their own.
🍚 A free trick: cook, cool, then reheat
Here's a genuinely useful tactic for the starchy foods near the top of the table. When you cook rice, pasta or potatoes and then chill them in the fridge — ideally overnight, or at least a few hours — some of the digestible starch reorganises into type-3 resistant starch (a process called retrogradation). Your small intestine can't break this form down, so it reaches the bloodstream far more slowly and feeds your gut bacteria instead, lowering the glycaemic load of the same food. Contrary to a widely repeated belief, you don't have to eat it cold and reheating doesn't undo it: retrograded starch is heat-stable, so a normal reheat keeps most of the benefit. In controlled human trials, white rice that was cooked, cooled for 24 hours and then reheated produced a lower blood-glucose response than freshly cooked rice — and actually held the most resistant starch of the three (Sonia et al., 2015), with similar findings since for cooled-and-reheated pasta and potatoes. The effect is real but modest — a gentler curve, not a free pass — and it stacks with the tactics above. Practical version: batch-cook your rice and pasta, refrigerate, and reheat from cold; yesterday's leftovers are metabolically a little kinder than the fresh-cooked plate.
Glycaemic load is calculated the standard way (glycaemic index × available carbohydrate per portion ÷ 100), with the low/medium/high bands ≤10 / 11–19 / ≥20. The teaspoon figure is the same quantity re-expressed using Dr Unwin's NICE-endorsed method — the glycaemic load of a serving ÷ the glycaemic load of one 4g teaspoon of table sugar (≈2.6), rounded to the nearest teaspoon — so each food's GL is roughly its teaspoons × 2.6. Anchor values (basmati rice 150g ≈ 10.1 tsp; banana 120g ≈ 5.7; apple 120g ≈ 2.3; wholemeal bread 30g slice ≈ 3) are taken directly from Unwin's charts; others are computed the same way from standard glycaemic-index and portion-carbohydrate data and will vary by brand, ripeness, variety and cooking method.
✓ Eat regularly
- Oily fish 2-3×/week: salmon, mackerel, sardines, trout, herring (the strongest evidence base for cardiovascular benefit)
- White fish: cod, haddock, pollock, sea bass, halibut — very lean, high protein, low saturated fat
- Shellfish: prawns, mussels, oysters, scallops, crab — low fat, high protein, B12-rich
- Chicken breast (skinless): the standard lean protein staple — grilled, baked, poached, in soups and salads
- Turkey breast / lean turkey mince: even leaner than chicken; excellent for mince-based meals (chilli, bolognese, meatballs, burgers)
- Lean chicken mince (5% fat): direct substitute for beef mince in most recipes
- Lean beef mince (5% fat) and trimmed lean cuts (fillet, sirloin, rump): up to 2-3×/week in moderate portions (~100g per meal)
- Venison: naturally very lean (3-5% fat), iron-rich; substitute for any beef recipe
- Game: rabbit, pheasant, partridge — extremely lean, seasonal British options
- Legumes daily: lentils, chickpeas, beans (kidney, butter, cannellini, black) — soluble fibre + protein
- Tofu & tempeh: complete plant protein; tempeh is fermented and gut-friendly
- Edamame: whole soybeans, excellent snack or addition to salads/stir-fries
- Vegetables ≥5 portions/day, aim for half the plate — every meal where possible
- Salad daily: large mixed leaves (rocket, watercress, spinach, romaine) with raw vegetables, olive oil + lemon dressing — easiest way to hit fibre and polyphenol targets
- Mushrooms: oyster and shiitake contain beta-glucan (the same soluble fibre as oats)
- Seaweed (nori, wakame, dulse): iodine and magnesium, very low calorie
- Fermented vegetables: sauerkraut, kimchi (unpasteurised) — gut microbiome support
- Berries & pomegranate: 3-5 servings/week (polyphenols, anthocyanins)
- Apples & pears: soluble fibre (pectin); skin-on for full fibre benefit
- Citrus: oranges, lemons, satsumas. ⚠️ Grapefruit interacts with statins — avoid if on simvastatin/atorvastatin/lovastatin
- Avocado: monounsaturated fats, fibre, potassium — half to one per day
- Oats: rolled or jumbo oats, porridge, overnight oats — beta-glucan directly lowers LDL
- Quinoa, buckwheat, millet, amaranth: complete proteins, low GI
- Wholegrain spelt, barley, rye, freekeh: if you tolerate gluten — substantial soluble fibre
- Wholegrain bread (e.g. seeded rye, wholegrain sourdough): the fibre dramatically blunts the glucose spike of refined alternatives
- Nuts 30g daily: walnuts (omega-3), almonds, hazelnuts, pistachios, pecans
- Chia & flax seeds: soluble fibre. Note ALA omega-3 in flax does NOT replace marine EPA/DHA (see omega-3 supplement card)
- Pumpkin seeds: magnesium, zinc
- Hemp seeds: complete protein, favourable omega ratio
- Extra virgin olive oil 2-3 tbsp/day (single-estate preferred; the cardiovascular workhorse of the Mediterranean diet)
- Avocado & avocado oil: similar mono-unsaturated profile to EVOO
- 0% fat Greek yoghurt: high protein with minimal saturated fat
- Skyr or quark: similar profile — Icelandic/Eastern European equivalents
- Cottage cheese: high protein, low fat, excellent snack base
- Unsweetened plant milks: almond, oat, soy — fortified with calcium and B12 when possible
- Green tea / matcha: catechins, mild LDL reduction
- Filtered coffee (paper-filtered): anti-inflammatory; avoid unfiltered French press / cafetière — contains cafestol which raises LDL
- Sparkling water with lemon or lime: replaces sugary drinks
- Dark chocolate 70%+ : 20-30g/day (flavonols)
- Garlic, turmeric, ginger: anti-inflammatory flavour staples
- Fresh herbs: basil, parsley, coriander, dill, oregano — flavour without salt
✗ Limit or avoid
- Sugar-sweetened drinks: cola, sweetened coffee, sports drinks, energy drinks
- Fruit juice: even 100% pure juice — fibre removed, sugar concentrated; spikes glucose and triglycerides exactly like cola (NHS cap: 150ml/day max)
- Smoothies: blending fruit destroys cell structure and releases sugars; eat whole fruit instead, or make vegetable-heavy smoothies with minimal fruit
- "Diet" drinks & non-sugar sweeteners: WHO May 2023 guidance recommends against NSS for weight or chronic disease prevention; aspartame classified IARC Group 2B in July 2023. The goal is reducing sweetness exposure, not switching the source
- White bread, white pasta, white rice: stripped of fibre, drive insulin spikes
- Pastries, biscuits, breakfast cereals: most commercial cereals are 20-40% sugar
- Cakes, doughnuts, viennoiserie: combine sugar + refined flour + saturated fat in one hit
- Processed meats: bacon, sausages, salami, chorizo, ham, hot dogs, deli meat (WHO Group 1 carcinogens; high salt; high saturated fat)
- Fatty red meat cuts: ribeye, fatty lamb, pork belly, brisket — different from lean cuts which are fine in moderation
- Skin-on poultry, fatty mince (20%+ fat): use lean variants instead
- Pâté and fatty offal preparations: very high saturated fat
- Butter, lard, ghee, dripping in heavy daily use (small amounts occasionally are fine)
- Coconut oil & coconut milk: extensively marketed as "healthy" but very high saturated fat (~85-90%); use sparingly
- Hard cheeses in heavy use: cheddar, parmesan, halloumi — fine occasionally, not daily 100g portions
- Deep-fried foods: chips, fried chicken, tempura, doughnuts
- Trans fats: margarines with "partially hydrogenated" oils on the label, some processed baked goods
- Any alcohol raises triglycerides; zero is metabolically optimal. UK CMO guidance: ≤14 units/week with several drink-free days (see Alcohol & the liver callout below)
- Sweet cocktails & mixers: alcohol + sugar hits the liver twice — the worst combination for triglycerides
- Ready meals: typically high in saturated fat, refined starch, salt, and additives
- Fast food: combines all the above — saturated fat, refined carbs, sugar, salt
- "Healthy" granolas and cereal bars: often 25-40% sugar by weight
- Flavoured yoghurts: typically contain more sugar per serving than ice cream
Fish & their omega-3 content
Not all fish are equal. Oily fish deliver many times more EPA + DHA per serving than white fish. The general cardiovascular target is roughly 1g/day EPA + DHA combined (or 2-4g/day therapeutically for elevated triglycerides — see the omega-3 supplement card in Tier 1). Two servings of oily fish per week typically covers general CV needs; white fish are still excellent for protein but don't replace oily fish for omega-3.
| Fish (per 100g cooked) | EPA + DHA | Notes |
|---|---|---|
| Mackerel (Atlantic) | ~2.5g | Highest commonly available; UK-caught, sustainable |
| Salmon | ~2.0–2.3g | UK staple year-round; farmed slightly higher than wild |
| Herring | ~2.0g | Excellent value; fresh, pickled, or kippered |
| Sardines (canned) | ~1.5g | Cheapest source; bones provide calcium |
| Pilchards | ~1.5g | Mature sardines, same nutrient profile |
| Anchovies (canned) | ~1.4g | Concentrated flavour; small portions count |
| Tuna (fresh) | ~1.3g | Canned tuna in water much lower (~0.3g) |
| Trout (rainbow) | ~1.0g | Mild flavour; accessible UK supermarkets |
| Hake | ~0.4g | Sustainable UK option; white-fish category |
| Cod / Haddock | ~0.2g | Excellent lean protein; supplement omega-3 separately |
Milk — the hidden saturated fat that adds up, and the iodine you can't afford to lose
Most adults take in milk without really counting it: a splash in tea, a glass with breakfast cereal, a frothy latte, milk in porridge or coffee through the day. It adds up fast. A "small" daily intake of 400-500ml of whole milk delivers around 10g of saturated fat — half of an entire day's UK recommended maximum (20g) — and that's before any cheese, butter, yoghurt or cream. The same volume of skimmed milk delivers under 1g. For anyone targeting cholesterol or already eating a typical Western diet, milk is often the single biggest unnoticed saturated-fat source.
Switching to semi-skimmed or skimmed is the most-rehearsed health advice in the UK — but the conversation almost never mentions the other side of the equation: milk is the largest single source of iodine in the British diet, contributing around 40% of total daily iodine intake. And iodine is one of the few nutrients where deficiency has irreversible neurological consequences.
Here's the practical part. Fat content of milk has no effect on iodine content — whole, semi-skimmed and skimmed all deliver roughly the same iodine per ml (~30 µg per 100ml in conventional UK milk; lower in summer than winter; ~32-44% lower in organic milk; ~27-30% lower in UHT/long-life). So switching from whole to skimmed costs you nothing in iodine, but cuts the saturated fat dramatically. The trade-offs that do reduce iodine are: switching to organic, switching to UHT, or switching to most plant-based alternatives.
| Milk typeper 100ml | Sat. fatg | Sugarg (lactose) | Iodineµg | Calorieskcal | Proteing |
|---|---|---|---|---|---|
| Whole milk (3.6% fat) | 2.3 | 4.6 | ~30 | 65 | 3.5 |
| Semi-skimmed (1.7% fat) | 1.1 | 4.7 | ~30 | 47 | 3.6 |
| Skimmed (<0.3% fat) | 0.2 | 4.8 | ~30 | 35 | 3.6 |
| Cholesterol-focused diet | ≤ 200ml/day whole OR ≤ 400ml/day semi OR ≤ 500ml/day skimmed |
— | Hits ~140 µg iodine target with 450ml semi/skimmed | — | — |
| General healthy adult | ≤ 300ml/day whole OR ≤ 500ml/day semi OR ≤ 600ml/day skimmed |
— | ~450ml covers daily iodine need | — | — |
How to think about it. If you're managing cholesterol, the simplest win is to switch to semi-skimmed or skimmed for everyday use — you keep all the iodine, calcium, B12 and protein, but cut saturated fat by 50-90%. Aim for around 400-500ml total daily (across tea, coffee, cereal, porridge, and drinks) to comfortably hit the 140 µg iodine target. Going much higher than 500ml regularly starts to add meaningful calories and lactose load. Going much lower than 200ml without another iodine source (white fish, eggs, fortified plant drinks, iodised salt) puts you at risk of deficiency.
Values are typical UK retail averages and vary by season, region, brand, organic vs conventional, and processing method. Iodine concentration of UK milk has declined ~21% since 1996 (Quadram Institute, 2023). Saturated fat figures assume ~62% of milk fat is saturated.
If you're gluten-free — read this carefully
Gluten-free is essential for coeliac disease, wheat allergy, and confirmed gluten intolerance. It is not, however, automatically healthier than a normal balanced diet — and for cholesterol and metabolic health, many commercial gluten-free products are notably worse than the wheat-based originals they replace.
The reason is straightforward: removing gluten removes the structural protein that gives bread, pasta, and pizza their texture. Manufacturers replace it with rapidly-digested starches — typically rice flour, corn flour, tapioca, and potato starch — plus added sugars, gums, and oils. The result is products with a higher glycaemic load than ordinary wheat-based alternatives, driving exactly the insulin and triglyceride response we're trying to avoid.
🍞 GF bread, pasta, pizza, cereal
Rice/corn/tapioca flour bases hit the bloodstream as fast as glucose. Limit portion sizes, eat alongside protein/fat/fibre to blunt the spike, and use these as occasional foods rather than daily staples.
⚠️ Brown rice = arsenic
Rice is the world's largest dietary source of inorganic arsenic, and brown rice contains 60-80% more than white because arsenic concentrates in the bran. UK FSA advises limiting brown rice for adults, especially children. Rinse thoroughly, cook in excess water (6:1), drain — reduces arsenic by ~50%. Rotate with quinoa, buckwheat, millet, lentils.
🌾 Better GF whole grains
Choose quinoa, buckwheat, millet, amaranth, sorghum, teff, GF oats (certified) — naturally gluten-free, high fibre, no arsenic issue, much lower glycaemic impact than rice-flour products.
🥬 Skip the GF aisle entirely
The simplest fix is to eat foods that are naturally gluten-free: meat, fish, eggs, vegetables, legumes, fruit, dairy, nuts. Most of your plate should be these foods anyway. The processed GF aisle is for occasional convenience, not daily eating.
🚫 GF ≠ low-sugar
GF products often contain more added sugar than their wheat equivalents to compensate for texture loss. Always read the label — many GF cookies, cakes, and breads sit at 15-25g sugar per serving.
🍚 White vs brown rice trade-off
White rice has less arsenic but higher glycaemic impact. Brown rice has more fibre but more arsenic. Neither should be a daily staple — alternate with quinoa, buckwheat, and lentils as your primary grains.
Alcohol & the liver
The liver prioritises clearing alcohol above all other metabolic tasks — including fat oxidation. While alcohol is being processed, lipid clearance, glycogen handling, and triglyceride metabolism are paused. Heavy or regular drinking is an established driver of liver disease and elevated triglycerides, and even moderate drinking has been re-evaluated downward in recent guidelines.
UK Chief Medical Officers' guidance: men and women should drink no more than 14 units per week, spread over three or more days, with several drink-free days. This is the low-risk benchmark, not a target. Lower is better; there is no completely "safe" level.
The mixer trap: alcohol combined with sugary mixers (sweet cocktails, cola, sweetened tonic, juice mixers, regular beer in volume) hits the liver twice — with alcohol and fructose simultaneously. The liver clears alcohol first, leaving the fructose to feed straight into hepatic fat synthesis. Sweet cocktails are particularly bad for triglycerides.
Lower-impact choices if drinking: dry wines, clear spirits with soda water or sparkling water + lime. Avoid: sweet cocktails, regular cola mixers, sweetened tonic, sugary cider, and beer in volume. Spread drinking events across the week — a single big night is metabolically worse than the same units spread out.
Potassium & blood pressure — the cardiovascular co-pilot
High cholesterol and high blood pressure travel together — both share the same atherogenic mechanism (endothelial damage that lets LDL infiltrate the artery wall), and treating one without the other leaves cardiovascular risk substantially elevated. Potassium is the most under-recognised dietary lever for blood pressure, working in direct counterbalance to sodium: where sodium pulls water into the bloodstream and raises pressure, potassium relaxes blood-vessel walls and helps the kidneys excrete excess sodium.
The UK National Diet and Nutrition Survey consistently shows that most British adults eat too much salt and not enough potassium — the average sodium-to-potassium ratio in the typical UK diet is roughly the opposite of what's cardiovascular-optimal. The fix doesn't require special foods or supplements: it's already on the "eat regularly" list above. The UK adult target is approximately 3,500 mg potassium/day from food (slightly higher in the US at 4,700 mg).
🥑 Avocado · ~700mg
One whole avocado covers ~20% of daily target. The mono-unsaturated fat profile is a bonus.
🍠 Baked potato (skin on) · ~900mg
The highest single-portion potassium source in normal British food. Skin contains the bulk; don't peel.
🫘 Beans & lentils · ~700mg/cup cooked
White, kidney, butter beans, lentils — all excellent. Doubles as soluble fibre for LDL.
🍌 Banana · ~400mg
The famous source, though smaller than reputation suggests. Eat alongside other sources.
🥬 Spinach (cooked) · ~840mg/cup
Cooking concentrates the potassium dramatically. Raw spinach in salad delivers far less per portion.
🐟 Salmon · ~530mg/100g
Doubles up with your oily-fish omega-3 target. Tuna and mackerel are similar.
🍅 Tomato sauce/passata · ~900mg/cup
Concentrated tomato is one of the highest dietary sources. Choose low-salt varieties.
🍫 Dark chocolate 70%+ · ~210mg/30g
Small daily portion of high-cocoa chocolate is genuinely useful for both potassium and flavanols.
Stacking — the Portfolio Diet, and why the components matter less than the combining
Almost every cholesterol-lowering food on this page has been tested on its own, and almost every one comes back with a modest result: five to ten per cent off LDL. Individually that is easy to dismiss. The interesting question, which David Jenkins's group at the University of Toronto asked directly, is what happens when you do several at once.
The name is the argument. Rather than one large intervention, you hold several small ones and the returns compound — which is the same logic this site applies to lifetime apoB exposure, running the other way.
The five components, and their targets
| Component | Daily target | Where it comes from |
|---|---|---|
| Viscous (soluble) fibre | 20 g | Oats, barley, psyllium, aubergine, okra, apples, beans |
| Plant protein | ~50 g | Soy — tofu, tempeh, soy milk, edamame — plus lentils and chickpeas |
| Nuts and seeds | 45 g | A small handful. Almonds, walnuts, chia, flax; nut butters count |
| Plant sterols | 2 g | Realistically needs fortified products — in the UK, Benecol or Flora ProActiv |
| Unsaturated oils | ~45 g | Olive oil, avocado |
What it actually achieves, and the number to hold
The trial that matters is the one in real life. Jenkins and colleagues, JAMA 2011: 351 people with hyperlipidaemia across four Canadian academic centres, six months, eating self-selected diets at home rather than being fed.
- Portfolio advice: LDL down 13.8% (95% CI −17.2 to −10.3)
- Control — conventional low-saturated-fat advice: down 3.0%, and that did not reach significance
So roughly 13 to 14% against an active control, in people living normal lives. A pooled analysis of the controlled trials puts it at about 17%, and higher when it is layered on a low-saturated-fat diet as intended.
The 30% figure you will meet is real and comes from a different setting. Under metabolically controlled conditions — every meal provided — a month on the portfolio lowered LDL by 28 to 35%, and Jenkins ran it head-to-head against a statin to make exactly that point: −28.6% on the diet against −30.9% on 20 mg lovastatin.
That comparison is worth knowing and it is a ceiling, not an expectation. It describes what the components can do when adherence is total because someone else is cooking. The number to plan around is 13–17%. This site applies the same discipline to DiRECT's remission figures, and to AREDS2: the population a result came from is part of the result.
The most useful finding in the trial is the one nobody quotes
The 2011 trial had two portfolio arms: intensive advice, at seven clinic visits over six months, and routine advice, at two. They did not differ — 13.8% against 13.1%, P = 0.66.
Which means the benefit is in the food, not in the supervision. You do not need a programme, an app, or a coach. Two conversations and a shopping list got the same result as seven. That is unusual in dietary trials and it is the single most encouraging thing on this page.
The practical frictions, honestly
- Plant sterols are the component you cannot reach from whole food. Two grams a day realistically means a fortified spread, yoghurt drink or supplement. Everything else on the table is groceries; this one is a product.
- Viscous fibre at 20 g takes spreading across meals. Oat or barley bread gives 2–4 g a slice, a bowl of oat cereal 4–6 g, and fruit and vegetables like apples, oranges, berries, aubergine and okra 1–2 g a serving. Psyllium is the shortcut at 2–4 g a teaspoon, and it is what the calculator already suggests.
- It is not all-or-nothing. Partial adherence gives partial benefit, and the trial's own analysis found the reduction tracked how closely people followed it.
- It is not vegan. Plant-forward, and it accommodates small amounts of animal food.
- Give it four to eight weeks before judging, and get a baseline first — a single reading either side of a change cannot tell you much, for the reasons chapter 2 sets out.
Two things this site has to say about it
Response varies a great deal between people, and there is a plausible mechanism: how much cholesterol you absorb from the gut against how much your liver makes. Heavy absorbers would be expected to respond more to the sterol and fibre components, which act on absorption. That is a reason to measure rather than assume, and it is an argument for the baseline reading above.
And the surrogate question, which this site asks of everything. There is no trial of the Portfolio Diet with heart attacks as an endpoint, and there probably never will be — nobody can fund or blind one. What exists is LDL reduction, plus observational cohort evidence that higher adherence tracks lower cardiovascular risk.
That is a weaker position than a drug trial and a stronger one than most dietary claims, and the reason is specific: LDL is the one surrogate on this site treated as well-validated, because lowering it reduces events across four pharmacologically distinct mechanisms and the genetics point the same way. A diet that lowers apoB-carrying particles is therefore on firmer ground than one justified by a biomarker nobody has ever moved to an outcome.
Graded Strong for lowering LDL and Moderate for reducing cardiovascular events, which is inferred from the LDL evidence rather than demonstrated directly.