When my dad was diagnosed with heart disease at 78, doctors immediately wanted to “roto-root” his coronary arteries. I stopped them and asked, “What’s next? How do we prevent his arteries from continuing to build plaque?” This led us to advanced testing that revealed a genetic mutation called MTHFR, which prevented him from properly converting the B vitamins in food into usable fuel for his body. A simple methylated B vitamin supplement made a dramatic difference, and five years later, he’s thriving with just lifestyle modifications.
Fast forward to today, where I’m applying what I learned through my dad’s experience to help people with Peripheral Artery Disease (PAD) through the Global PAD Association. I’m frustrated by the revolving door of procedures where doctors just “roto-root” leg arteries without addressing the underlying causes of plaque buildup. That’s why I was thrilled to bring Dr. Lily Johnston, a vascular surgeon from Scripps in San Diego, onto our recent episode of The Heart of Innovation. She’s not just treating blocked arteries but working to prevent them from becoming blocked in the first place.
Early Detection: Finding Arterial Disease Before Symptoms Appear
“What drives my passion is recognizing that this is a long disease process,” Dr. Johnston explained during our conversation. “It takes decades for plaque to form and accumulate, and then rupture and become a huge problem. If we could only get patients earlier in this disease process, we would have an opportunity to really dig deep into these metabolic risk factors that drive the progression of plaque buildup or atherosclerosis.”
The contrast between how we approach cardiovascular disease versus other conditions is striking. We have normalized cancer screenings through mammography, colonoscopy, and lung cancer tests, yet cardiovascular disease—the leading cause of death worldwide—lacks standardized early detection protocols.
Dr. Johnston uses several imaging techniques for early detection that could identify arterial disease years or even decades before symptoms appear. She explained, “We can talk about coronary calcium score, CCTA or coronary CT angiography. We can talk about CIMT (Carotid Intima-Media Thickness), which is not super popular in the cardiology space, but is something I’ve used very successfully in my practice.”
CIMT is particularly valuable as it measures the thickness of the inner layers of the carotid artery to detect early arterial thickening and plaque. It’s non-invasive and doesn’t involve radiation, making it an excellent screening tool that more doctors should utilize. But detecting disease is only half the battle—understanding who’s at risk is equally crucial.
The Metabolic Syndrome Reality: Nearly 9 in 10 Americans at Risk
Early detection becomes even more critical when we consider how widespread metabolic risk factors actually are. Dr. Johnston referenced research from the National Health and Nutrition Examination Survey (NHANES) showing that only about 12% of American adults are metabolically healthy—meaning they have optimal levels of all five key factors: blood glucose, triglycerides, HDL cholesterol, blood pressure, and waist circumference without medications. This research, published by the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health in 2018, analyzed data from 8,721 people between 2009 and 2016.
“If you look at the United States and take the NHANES data and ask how many people meet zero out of five criteria for metabolic syndrome… it’s about 12%, or maybe even less now,” Dr. Johnston noted. This widespread metabolic dysfunction is driving the epidemic of arterial disease we’re seeing today.
The good news? Targeting insulin resistance—which Dr. Johnston identifies as the root cause—can improve all these markers simultaneously. “If we target the root of insulin resistance, we can actually improve all those markers of metabolic syndrome because that’s how they’re related,” she explained. Identifying these risk factors early requires going beyond standard medical testing.
Advanced Testing: Beyond Basic Cholesterol Panels
With metabolic syndrome affecting so many Americans, standard cholesterol testing simply misses too much critical information about what’s actually happening in your arteries. Dr. Johnston’s approach includes comprehensive assessments that reveal a much more complete picture:
“Our initial lab panel covers a broad swath of things. We do advanced lipid testing. We do metabolic testing, including fasting insulin, fasting glucose. We’ll check homocysteine and uric acid, Lp(a), little a. And I offer patients an opportunity to check their ApoE genotype because that may impact recommendations in terms of risk for Alzheimer’s disease and cardiovascular disease.”
The advanced lipid testing she mentions goes far beyond the standard cholesterol panel. It includes particle numbers and sizes, which are often much better predictors of cardiovascular risk than standard LDL measurements. Homocysteine testing can reveal issues with methylation pathways (like my father’s MTHFR mutation), while Lp(a) is a genetic risk factor for accelerated atherosclerosis that many doctors never check.
Dr. Johnston confirmed this comprehensive approach works: “For patients like Kim’s dad with elevated homocysteine and an MTHFR mutation, I would employ a methylated B vitamin to try to bring that homocysteine down and reduce the risk of particularly stroke, but also major adverse cardiac events.” But beyond these specific markers, inflammation emerged as perhaps the most significant modifiable risk factor in our discussion.
Inflammation: The Arterial Damage You Can’t Ignore
While advanced lipid and metabolic testing provide valuable insights, understanding inflammatory processes may be even more critical for preventing arterial disease. “Inflammation is an enormous opportunity for us to get involved and try to reduce risk,” Dr. Johnston emphasized. “We should absolutely be testing for it and trying to intervene when we find it.”
However, she cautions against treating inflammation without understanding its source: “We know that just treating the immune system comes with a cost. We have reduced cardiac events, which is great. But we’ve actually increased infections when all we do is suppress the immune system.”
Dr. Johnston advocates finding the underlying causes: “Why do we have inflammation? Is it visceral adiposity or visceral fat accumulation? Is it periodontal disease? Is it untreated sleep apnea? Understanding why, rather than just suppressing the immune system—that’s where we get the magic.”
Many of my PAD patients don’t realize that inflammation is often the driving force behind their arterial disease. Simply measuring high-sensitivity C-reactive protein (hsCRP) and addressing sources of inflammation can make a dramatic difference in disease progression. And among those inflammatory drivers, one condition stood out in our conversation as particularly important yet frequently overlooked.
Sleep Apnea: The Hidden Cardiovascular Risk Multiplier
When discussing sources of inflammation, Dr. Johnston highlighted sleep apnea as a remarkably powerful risk factor that most physicians miss. She shared research showing that treating sleep apnea can cut the risk of heart attack and stroke in half.
“If you have sleep apnea and you treat it, it will cut your risk of heart attack and stroke in half,” she stated. “This is amazing—reduced cardiac events. Number needed to treat is like 3.” A “number needed to treat” of 3 means that for every three people with sleep apnea who get proper treatment, one major cardiovascular event is prevented—an extraordinarily powerful intervention.
When I asked about the rising prevalence of sleep apnea, Dr. Johnston provided fascinating context: “Correlation with a diagnosis of obesity is high, but there are people with deviated septums and weird jaw anatomy. If you read the book ‘Breath’ by James Nestor, he talks about how we don’t chew crunchy food anymore, and it’s changed our facial anatomy.”
Many of my PAD patients have undiagnosed sleep apnea. Getting proper sleep testing and treatment can be life-changing for their arterial health, often more so than medications or procedures. This exemplifies why patient education and involvement in their own care is so critical for long-term success.
Patient Empowerment: Taking Control of Your Vascular Health
With so many factors affecting arterial health—from metabolic markers to inflammation to sleep quality—patients need to become active participants in their care. Dr. Johnston’s practice embodies this philosophy. Her initial consultation lasts two hours and covers lifestyle pillars including nutrition, movement, sleep, stress, social connection, and toxic disruptors. She even performs point-of-care ultrasound to check carotid arteries for evidence of inflammation or plaque.
This comprehensive approach is exactly what’s needed to break the cycle of “sick care” that dominates our healthcare system, especially for PAD patients caught in the revolving door of procedures.
“If you want to make the most out of that visit with your doctor, you are empowered and have the responsibility to make it as easy for your physician as possible to really dive into the issue at hand,” she explained. This means coming prepared with your medical history, medication list, and specific questions based on your research. But empowerment isn’t just about gathering information—it’s about creating sustainable changes that improve health over time.
Realistic Health Improvement: Starting Where You Are
Perhaps the most refreshing aspect of Dr. Johnston’s approach is her commitment to meeting patients where they are. Rather than overwhelming them with complete lifestyle overhauls that feel impossible to maintain, she advocates starting with achievable changes:
“Pick the low hanging fruit. What feels achievable and get a win—get a checkbox in your book that says ‘I did this for me, and I did it, and I feel better.’ And now I can do another thing. We prove to ourselves that we are worth it, that these interventions are worth it, and we build our own confidence.”
She acknowledges that not every intervention works for every patient and that personalization is key: “I can offer you a solution that’s nutritionally based. We can focus on your nutrition or your exercise. Let’s talk about structured exercise. Or let’s work on your sleep hygiene and getting you tested for sleep apnea. Or let’s talk about your connections and your social and your stress.”
For PAD patients who’ve been told to just “stop smoking and exercise more,” this personalized approach offers real hope for breaking the cycle of recurring blockages. By focusing on specific, actionable steps, patients can begin making meaningful progress immediately.
Taking Action: Steps Toward Healthier Arteries
Based on our conversation with Dr. Johnston, here are key actions anyone concerned about arterial health should consider:
Request advanced testing beyond standard cholesterol panels, including inflammatory markers, homocysteine, Lp(a), and insulin resistance, fasting glucose
Consider screening for sleep apnea, especially if you have cardiovascular risk factors or don’t feel rested after sleeping
Focus on addressing insulin resistance and diabetes through diet and lifestyle modifications sooner rather than waiting until it leads to vascular complications.
Prepare thoroughly for medical appointments, bringing complete medication lists and medical history
Start with one achievable health change rather than trying to transform everything at once
As Dr. Johnston put it: “Let’s start with one thing that feels like you want to tackle it, that’s easy and achievable, and do it and check that box and then be brave and pick another one and go from there.”
The Future of Arterial Health: Prevention Over Procedures
Dr. Johnston represents the vanguard of a new approach to arterial health—one focused on prevention, early detection, and treating root causes rather than symptoms. “My mission is to put myself out of business as a surgeon,” she told us, highlighting her commitment to preventing the need for invasive procedures whenever possible.
Her integrative approach combines the best of conventional medicine with evidence-informed nutritional and lifestyle interventions. By addressing metabolic dysfunction, inflammation, and other root causes of arterial disease, we can prevent countless heart attacks, strokes, and limb-threatening conditions.
At the Global PAD Association, we’ve long advocated for this comprehensive approach to vascular health. Dr. Johnston’s work validates what we’ve seen in countless patients—that addressing the underlying causes of arterial disease can dramatically improve outcomes and quality of life.
To learn more about Dr. Johnston’s approach to vascular health, visit Vascular Health Institute at www.vascularhealthinstitute.org or connect with her on LinkedIn at Lily Johnston MD.
For more resources on managing peripheral artery disease and heart health, visit padhelp.org or call the Global PAD Association’s Leg Saver Hotline at 833-PAD-LEGS. Also, tune in to The Heart of Innovation podcast for ongoing conversations with leading experts in vascular health at Youtube.TheWayToMyHeart
