Everybody seems to be talking about the new USDA food pyramid. It’s everywhere right now. Headlines. Social media debates. Doctors weighing in with grades like it’s a report card. And much of the conversation sounds like it’s happening in a vacuum, as if food choices exist independently of disease.

That’s why, during a recent episode of our weekly NextGen MD series, I wanted a vascular surgeon’s perspective. Not a diet influencer. Not a policy expert. A surgeon who sees arteries every day. Someone who lives at the intersection of food, metabolism, and what actually happens inside blood vessels over time.

Dr. Lily Johnston was the obvious choice.

She didn’t dismiss the new guidelines. In fact, her first reaction surprised some people. She was generally positive. She liked the emphasis on whole foods and the move away from grain-heavy guidance. She agreed that protein deserves a more prominent role. But she also made something clear very early on that tends to get lost in public conversations about nutrition.

“These guidelines are for a healthy population,” she said. People without chronic disease. People trying to avoid getting sick.

They are not a therapeutic prescription.

That distinction matters more than most people realize.

Because the moment you introduce diabetes, atherosclerosis, cardiovascular disease, autoimmune disease, or peripheral artery disease into the picture, the rules change. The goal is no longer prevention in the abstract. It’s management. Stabilization. Sometimes reversal. And that requires a level of customization no pyramid can offer.

We talked about protein first, because that’s where much of the current noise lives. Steak has become the lightning rod. Some praise it. Others panic. Dr. Johnston didn’t take either extreme. She talked about quality, sourcing, and biology. Ruminants, she explained, have a unique ability to detoxify certain compounds through their digestive systems. That doesn’t make steak a free-for-all, but it does complicate the simplistic good-versus-bad narrative.

Fish came up next, and here she slowed the conversation down. Yes, fish is important. But not all fish is equal. Farming practices, heavy metals, and microplastics matter. Chicken and pork raised on poor-quality feed raise their own concerns. None of this fits neatly into a graphic.

Vegetables, she emphasized, are still foundational, but not in the vague, “eat more greens” way patients usually hear. She talked about vegetables as a vehicle for micronutrients, fiber, and metabolic signaling, not as a box to check. Leafy greens, cruciferous vegetables, and fiber-rich plants play a role in endothelial health, inflammation, and insulin sensitivity, but preparation and tolerance matter. Raw isn’t always better. Overloading patients with roughage when they already have gut issues or poor absorption can backfire. For some, lightly cooked vegetables improve tolerance and nutrient availability. For others, certain vegetables drive bloating or glucose spikes that undermine the very goals they’re trying to achieve.

She also pointed out that vegetables don’t work in isolation. Pairing them with adequate protein and fat changes glycemic response and satiety. A plate built around vegetables but devoid of protein, she noted, often leaves patients hungry, snacking, and frustrated. The goal isn’t volume for volume’s sake. It’s using vegetables strategically, in a way that supports metabolic stability rather than competing with it.

When the conversation turned to chronic kidney disease, I pushed back, repeating what so many patients tell us. They’ve been warned that protein is dangerous. That eating more will accelerate decline.

Dr. Johnston didn’t dismiss those fears, but she challenged the certainty behind them. She pointed to emerging evidence showing improvement in kidney markers among some patients following therapeutic carbohydrate reduction. Polycystic kidney disease came up. So did the fact that data exists on both sides.

Her message wasn’t that everyone should eat the same way. It was that patients deserve more than one set of papers and one interpretation. Nutrition decisions should be made with data, context, and a clear understanding of what problem you’re trying to solve.

That theme continued as questions came in live.

Alcohol. Mediterranean diets. Wine. Europe versus the United States.

Dr. Johnston was candid. Alcohol is a toxin. Sleep suffers. The supposed benefits of resveratrol, in her view, have largely been debunked. Mediterranean populations differ in more ways than wine consumption. Food processing, wheat varieties, farming practices, and additives all matter. She wasn’t telling anyone to never enjoy a glass of wine. But she was clear that no one should drink for their health.

When a PAD patient asked how to interpret the pyramid specifically for their disease, Dr. Johnston went straight to root cause. If PAD is driven by diabetes or insulin resistance, starches shrink dramatically. Sugars go. Nutrition becomes a tool to target endothelial dysfunction, not a moral exercise.

If inflammation from visceral adiposity is the driver, then fat loss becomes the priority. Different mechanism. Different approach. Same principle.

“What exactly are we trying to treat?” she kept asking.

That question echoed again when supplements came up. Her answer was refreshingly unromantic. Supplements are drugs. They should have indications. They should have measurable outcomes. Quality matters. Certification matters. Taking something “just because” isn’t benign.

She shared practical examples. Magnesium glycinate for sleep. Omega balance testing before fish oil. Homocysteine to guide B vitamin decisions. Not trends. Tools.

As the discussion moved into olive oil, oatmeal, and breakfast rituals, the tone softened. Real life entered the room. Steel-cut oats versus quick oats. Seeds. Fiber. Protein. What worked for my dad. What works for one patient but not another. Microbiomes. Genetics. Tolerance.

No pyramid can tell you that.

“Some of this is your own N equals one experiment,” she said. Paying attention. Testing. Adjusting. Accepting that different bodies respond differently.

Even when eggs came up, the answer wasn’t prescriptive. Total cholesterol is a blunt instrument. ApoB matters more. Most people don’t see cholesterol rise with eggs. Testing before and after matters more than dogma.

Over and over, the conversation returned to the same quiet truth. Nutrition is not a belief system. It’s a strategy. And strategies should change depending on the problem in front of you.

That’s why the new food pyramid can be a starting point, but it can’t be the destination. Especially for patients living with PAD, diabetes, kidney disease, or cardiovascular disease. They deserve more than a graphic. They deserve care that acknowledges complexity.

And they deserve clinicians willing to say, “It depends,” and then help them figure out what it depends on.

For patients navigating peripheral artery disease and related conditions, education and access to experts matter. For questions about PAD, risk factors, and treatment options, call the Leg Saver Hotline at 1-833-PAD-LEGS or visit www.PADhelp.org. Join our patient community at www.padsupportgroup.org.

You can watch this full episode, along with weekly conversations with leading clinicians, on our NextGen MD series at youtube.com/@thewaytomyheart. Dr. Lily Johnston also shares education and insights on her channel at youtube.com/@lilyjohnstonmd.

We also host weekly office hours on diet every Monday from 3:00–3:30 pm Eastern with world-renowned diabetes reversal physician Dr. Michael Dansinger, where patients can ask real questions and get grounded answers.

This is where the nuance lives.