Catherine McManus, PhD, RDN, LD, is an assistant professor of nutrition at Case Western Reserve University; Cleveland Clinic Foundation, Department of Reproductive Biology and OB/GYN.

Catherine McManus, PhD, RDN, LD

Cultural Diversity, Personalization, and Meeting Patients Where They Are

In the final segment of the discussion, Colleen Sloan highlighted what she viewed as a notable omission from the dietary guidelines: the lack of explicit inclusion of culturally diverse foods. She noted that this absence can unintentionally lead patients to question whether their traditional or cultural foods are now considered “unhealthy,” or reinforce existing biases that equate certain ethnic cuisines with poor nutrition.

Slaon emphasized that the guidelines missed an opportunity to clearly affirm that healthful dietary patterns can and should exist across many cultural traditions. She asked how clinicians can respond when patients express concern that their cultural foods are not reflected in the guidelines.

Catherine McManus underscored that food is deeply intertwined with culture, tradition, family, and community, making drastic dietary changes neither feasible nor respectful for most patients. She stressed that asking someone to abandon their cultural dietary pattern altogether fails to honor the central role food plays in quality of life and social connection. Instead, she advocated for a collaborative approach that works within a patient’s existing food patterns.

Rather than focusing on restriction, McManus described strategies centered on addition and modification. She emphasized the concept of “crowding out,” encouraging clinicians to ask what healthful foods can be added to a patient’s diet, rather than framing recommendations around eliminating familiar foods. Over time, these additions can naturally displace less healthful options without creating a sense of deprivation.

She also highlighted practical strategies such as 50/50 swaps—for example, combining white rice with brown rice, acknowledging that staples like white rice are foundational in many cultures and should not be dismissed as inherently unhealthy. These incremental changes allow patients to maintain cultural identity while still moving toward improved nutritional quality.

Viet Le echoed these sentiments, emphasizing the importance of grounding recommendations in both science and compassion. He described his approach as first explaining the evidence and what is considered optimal, then shifting the focus to understanding where the patient currently is without judgment or guilt.

From there, the goal becomes working collaboratively to make achievable changes. Le noted that most patients want to be healthy and live high-quality lives; when they are given clear reasoning rather than rigid mandates, they often become curious and open to change. He cautioned against “putting the hammer down,” emphasizing that overly prescriptive approaches rarely lead to sustainable behavior change.

Slaon closed the conversation by thanking both speakers and reinforcing the central takeaway: while dietary guidelines outline population-level ideals, effective nutrition counseling happens one patient at a time. By staying curious about patients’ backgrounds, cultures, and capacities, clinicians can help individuals take small, meaningful steps toward better health without sacrificing identity, dignity, or quality of life.

, pediatric physician assistant and registered dietitian.

, assistant professor of nutrition, Case Western Reserve University; Cleveland Clinic Foundation.

, preventive cardiology physician assistant and associate professor of research, Intermountain Health.

US Department of Health and Human Services. Kennedy, Rollins Unveil Historic Reset of U.S. Nutrition Policy, Put Real Food Back at Center of Health. January 7, 2026. Accessed February 4, 2026. 

https://www.hhs.gov/press-room/historic-reset-federal-nutrition-policy.html

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In the final segment, experts discuss how to navigate traditional or cultural foods with patients in the absence of their inclusion in the guidelines.

Food Access, Equity, and Removing Shame From Nutrition Guidance

In part 7 of the discussion, Colleen Sloan returned to a theme that had surfaced repeatedly throughout the discussion: access. She noted that a significant portion of the pushback surrounding the new dietary guidelines has centered on the perception that they feel elitist.

In many parts of the country, food deserts and limited access to affordable, “whole” or minimally processed foods remain a reality. For families living in these environments, Sloan emphasized that the guidelines can unintentionally create feelings of shame, guilt, or fear, particularly if patients feel that what they are able to feed their families falls short of what is being recommended.

Catherine McManus expanded on this by framing access as having two distinct components: physical access and financial access. Even when foods are theoretically available, they may not be accessible at a local grocery store, or they may be cost-prohibitive for many families. She pointed to examples within the guidelines, such as recommendations related to probiotics and gut health, that reference foods like kimchi, kefir, and miso. These items, she noted, are often more expensive and not widely available, making them unrealistic options for large segments of the population. McManus emphasized the responsibility of clinicians to recognize these barriers and to offer more accessible alternatives when discussing topics like the gut microbiome.

She also highlighted the importance of cultural sensitivity when translating guideline recommendations into practice. Many patients may be unfamiliar with or uninterested in foods such as kimchi or miso, may not know how to prepare them, or may not view them as culturally relevant. Understanding what foods patients are willing and able to incorporate into their diets and meeting them where they are was a central theme in her remarks.

Viet Le reinforced this perspective by returning to the idea of quality of life as a guiding principle. While the guidelines outline optimal choices based on population-level data, he emphasized that these recommendations are about risk reduction, not guarantees. In his view, counseling should focus on helping patients make the best choices possible within their individual circumstances, rather than striving for perfection. He stressed the importance of removing guilt from the conversation and reframing guidelines as aspirational rather than punitive.

Ultimately, Le argued that the role of clinicians is to translate the science into realistic, compassionate guidance that reflects each patient’s community, resources, and lived experience. By focusing on incremental improvements and achievable changes rather than idealized standards clinicians can help patients engage with nutrition recommendations without feeling judged or excluded.

In part 7 of the discussion, experts reflect on access issues regarding foods recommended in the guidelines.

Navigating Added Sugar Recommendations Across Different Age Groups and Clinical Contexts

In part 6 of the discussion, the conversation turned to one of the more contentious areas of the updated dietary guidelines: added sugars. Colleen Sloan noted that while recommendations to limit added sugars are not new, the most recent guidelines take a more restrictive stance, prompting debate about how realistic and applicable these recommendations are, particularly across different age groups and clinical contexts.

Catherine McManus began by outlining how the guidelines address added sugars in pediatrics. For early childhood, the recommendation is to avoid added sugars altogether, a position she fully supports given the well-established associations between added sugar intake and adverse health outcomes. However, in middle childhood, defined in the guidelines as ages 5 to 10, the recommendation goes further, stating that no amount of added sugar is recommended.

While McManus agreed with this principle in theory, she raised concerns about its practicality. Drawing on both research and clinical experience, she noted that overly restrictive guidance can backfire, turning certain foods into “forbidden” items that children may later overconsume when given the opportunity. Given that humans are physiologically wired to prefer sweet, salty, and high-fat foods, she suggested that framing the guidance around limiting or avoiding added sugars, rather than stating that no amount is recommended, may better support realistic, sustainable dietary behaviors.

Slaon echoed the need for nuance, particularly when working with adolescent athletes. She explained that for this population, foods containing added sugars can serve as effective, quick sources of energy before intense physical activity or long competitions. This, she emphasized, reinforces the idea that clinicians must interpret population-level guidelines through the lens of the individual patient. A recommendation that may be appropriate for an older adult with metabolic syndrome, for example, may not apply in the same way to an active teenager who metabolizes glucose very differently.

From the adult and cardiology perspective, Viet Le emphasized that the dietary guidelines are designed as broad, population-level guardrails rather than prescriptive rules for every individual. He stressed that the role of the clinician is to contextualize these recommendations based on each patient’s circumstances, resources, and goals. In practice, this means acknowledging real-world constraints such as work schedules, access to food, and socioeconomic factors, and helping patients make better or more optimal choices within those limitations. Le described this as a “good, better, best” framework, rather than an all-or-nothing approach.

He further noted that even within cardiology, patient needs vary widely, from individuals with limited access to fresh foods to athletes with established coronary disease who still aim to train and compete. For his patients, the added sugar guidance provides a reference point, but counseling often centers on overall dietary patterns, such as Mediterranean or DASH-style eating, with an emphasis on plant-forward choices and incremental swaps rather than drastic restriction.

Ultimately, he cautioned that overly rigid recommendations can lead to frustration and disengagement, whereas flexible, personalized guidance is more likely to support long-term adherence and meaningful health improvements.

Part 6 of the discussion takes a closer look at added sugar recommendations from the guidelines and scenarios where individualization may be needed.

Pediatric Gaps in the Dietary Guidelines

In part 5 of the discussion, the conversation shifted to pediatric-specific gaps in the updated dietary guidelines, with Colleen Sloan emphasizing that many of the concerns stem from how condensed the document has become.

While the guidelines are often interpreted through a clinical lens, she underscored that they ultimately function at a federal policy level, informing programs such as SNAP, school meal standards, and nutrition requirements in elder and assisted living facilities. From that perspective, the degree of shortening raises concerns, particularly in pediatrics, where more detailed guidance can directly support education, safety, and appropriate nutrition for vulnerable populations.

Catherine McManus pointed to one notable omission in the infant nutrition section: the lack of guidance on breast milk handling and storage. Although the guidelines appropriately encourage breastfeeding and recommend iron-fortified formula when breast milk is not available, previous versions also included practical information on safe handling.

McManus stressed that this omission is concerning given how vulnerable infants are during the first year of life, when their immune systems are still developing and they are especially susceptible to infection. As with other gaps discussed, she attributed this change largely to the significant condensation of the document, noting that safety-related guidance for infants is particularly important to retain.

Sloan also highlighted the absence of a clear recommendation to avoid honey in infants under one year of age, a long-standing and critical safety message due to the risk of botulism. In addition, she noted that guidance on iron intake for infants and young children was far less prominent than in prior versions.

While iron was mentioned, it lacked the emphasis and specificity that previously helped clinicians and caregivers understand its importance, particularly concerning given how common iron deficiency is in early childhood.

Expanding on this point, McManus agreed that although iron and vitamin D were included, the discussion was extremely brief compared with earlier guidelines. She emphasized that prior versions did a better job outlining iron-rich food sources and explaining why adequate iron intake is essential during infancy and early childhood.

McManus also noted the missed opportunity to educate caregivers on the differences between heme and non-heme iron sources, including their relative bioavailability, which can have meaningful implications for absorption and utilization. Given the frequency of iron deficiency not only in the first year of life but extending into toddlerhood and the preschool years, she emphasized that more robust, practical pediatric nutrition guidance would be a valuable area for improvement in future guideline updates.

In part 5 of the discussion, the panel examines gaps within the pediatric sections of the updated dietary guidelines.

Catherine McManus, PhD, RDN, LD

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