Dr. Lily Johnston: Treating the Fire in Your Arteries, Not Just the Smoke

Why did Dr. Lily Johnston of Scripps in San Diego earn the Global PAD Association's 2025 Global Excellence in Transformative PAD Prevention and Management Award?

In my years advocating for peripheral artery disease awareness, I’ve seen countless approaches to treatment, but Dr. Johnston’s work truly stands apart.

What makes her special?

While many vascular specialists do a great job opening blocked arteries, it never fails that patients return repeatedly for the same procedure. Dr. Johnston digs deeper to address why those blockages form in the first place in order to stop the revolving door or at least delay it.

“The operations that I perform are an anatomic solution to a system-wide body problem,” she explained during our award interview. “One of the reasons that our patients have this revolving door of ongoing procedures is because we haven’t done anything with procedures alone to address the illness that caused this plaque to form.”

Dr. Johnston describes PAD using a powerful analogy that resonates deeply with patients: “Whatever started this fire in the arteries that is causing plaque to form will keep happening if we don’t do something to understand why it’s happening in the first place and try to nip that in the bud.”

This isn’t just talk.

She’s developed comprehensive assessment methods focused on the metabolic and inflammatory factors that are often overlooked in standard care.

Her evaluation begins with what she calls “the boring stuff, but it’s really critical” - markers of metabolic syndrome: blood pressure, triglycerides, HDL cholesterol, fasting glucose, and waist circumference. “If you have three or more, that is a diagnosis of metabolic syndrome,” she notes. “And what do we get before we get diabetes? We get pre-diabetes, which is an insulin resistant state.” This early identification matters because inflammation plays a central role in arterial damage. As Dr. Johnston explains, “Inflammation and oxidative stress is really what sets things off in the artery wall, creates an injury that then needs to be repaired. Plaque is just the body’s attempt to repair an injury in the blood vessel wall.”

Given the importance of early detection, Dr. Johnston raised a point during our conversation that many of us in the PAD community have been advocating for years since 3 in 5 people who suffer from a heart attack have PAD:

“Why on earth do we not have mandated screening for the number one leading cause of death in the country and in the world? We screen for breast cancer and prostate cancer and colorectal cancer, but not cardiovascular disease.”

This oversight has serious consequences.

By the time most PAD patients experience symptoms, they already have significant disease. “By the time you come to me with pain in your legs when you walk, we think that represents an 80% narrowing in your artery somewhere,” she explained.

The opportunity lies in catching issues earlier: “What if we could figure out that you were prone to developing this when it was a 10 to 20% piece of plaque in the artery that did not limit blood flow? Now we don’t have to pick out the big guns necessarily.” Early intervention allows for more moderate measures that can dramatically alter a patient’s trajectory.

Speaking of interventions, I asked Dr. Johnston about the STRIDE trial and whether medications like Wegovy and Ozempic are making a difference for PAD patients. Her answer illuminated the connection between these popular drugs and vascular health. “The incretin mimetics or GLP-1 receptor agonists are helping us understand the role of metabolism in cardiovascular disease,” she said. “Reduction of visceral adiposity, or the fat that builds up around the organs—that fat is inflammatory.” These medications provide clinical evidence of how metabolic improvements can benefit cardiovascular health. However, Dr. Johnston emphasizes that expensive injectables aren’t the only answer: “Does everybody have to get there through an expensive injectable medication? No. Do we have other strategies and things we can employ that may contribute to improved metabolic health before we get to those medications? Absolutely.”

What I particularly love about Dr. Johnston’s methodology is her practical “menu approach” that makes change manageable for patients who might otherwise feel overwhelmed by multiple recommendations.

“What I offer people is a menu of things. Look at all the different things we could do. Which of those feels easy right now? Pick one, just pick one,” she advises.

This might mean eliminating sugar-sweetened beverages, improving sleep, or committing to a 15-minute daily walk.

“Get a win and then build that confidence in yourself that you have capacity to change. And then as you build that confidence, then we move on to harder things.”

This approach makes so much sense in practice.

I saw it work firsthand with my own father, who at 83 is still making smart choices. Just recently, he called me excitedly after a dinner out where he’d ordered both a beet salad and lamb chops. Instead of just eating a few bites of salad to save room for the meat, he finished the entire beet salad first, focusing on what was healthiest. He was so proud of himself for this small but meaningful choice!

As patients experience these small successes, they begin to reconnect with how good it feels to be healthy.

“I think part of the problem in our current society,” Dr. Johnston notes, “is we have so many things that make us unwell that we forget what it feels like to feel good.”

Part of feeling good includes addressing all aspects of health, including supplementation – another area where Dr. Johnston’s approach stands out. One of the top three questions we get from PAD patients is about supplements. Patients are desperately seeking guidance, yet many clinicians dismiss supplements entirely or avoid the conversation. Dr. Johnston takes a measured approach:

“I treat supplements like medications. They are an exogenous substance that we are giving or taking to achieve a very specific effect.”

Rather than having a standard stack for everyone, she tailors recommendations based on advanced testing and individual needs. Her evidence-based method involves honest conversations about what the research does and doesn’t support. “Is there evidence that supplementing vitamin D above and beyond a critical level will absolutely reduce your risk of heart attack or stroke? Absolutely not,” she emphasizes. “But I do think that there is some evidence that it may support good immune function.”

But she doesn't believe in supplementation without appropriate investigational blood work to show where someone may be deficient to better discuss proper dosing.

It's nice to see a doctor who goes beyond conventional treatments, performs advanced testing on nutrient and mineral deficiencies that may be impacting artery health, and seeks evidence for alternative options. Supplements are in front of patients every single day and tough for them to ignore and not buy into with great marketing. So, having a doctor who is willing to have a productive conversation and explore safe options for patients who want to take additional steps to improve their health, is critical

This resonates with my own experience. When my mother and I sought advanced metabolic testing and asked her doctor about supplements, the doctor dismissively said, “Well, I hope you feel like you’re getting your money’s worth. I don’t believe in supplements. They don’t do anything.” This isn’t what patients need to hear when they’re trying to take control of their health! We know some supplements help such as turmeric, ceylon cinnamon, beet root powder, and even fish oil. But they need direction -- at least a conversation. And that's what Dr. Johnston prides herself in during her extended consults, which she recognizes not all physicians have the opportunity to provide.

The challenge, as Dr. Johnston acknowledges, is that our healthcare system doesn’t accommodate the in-depth conversations required for truly personalized care: “These discussions are not brief. They are not black and white or entirely straightforward. There’s not a blanket set of recommendations that I can make for every patient.” She’s created a solution by developing “a separate approach clinic and a separate template” for these patients. But she recognizes not every specialist can do this and encourages patients to advocate for themselves by requesting referrals to dieticians, cardiologists, and other specialists who can provide targeted support. “I recognize that I am a bit of a unicorn and not every surgeon wants to have these conversations,” she admits. “They want their patients to do well. Don’t misunderstand me. They absolutely want their patients to do well, but most of them do not feel confident or empowered to do a lot of what I do.”

This acknowledgment of healthcare’s limitations brings a human element to her practice – something that became profoundly evident when I asked her about a defining case. She shared a moving story about a patient with severe Parkinson’s disease and limb-threatening ischemia. After multiple discussions, he opted for palliative amputation but passed away from complications days later. “I was haunted by my choices,” she admitted. Then she received a card from his family expressing gratitude for her compassion. “The lesson for me was it doesn’t really matter what you pick and it’s not your choice. It’s his. It’s your patient’s choice. And sometimes the best healing we do is with our hearts, not our scalpels.” This perfectly captures why Dr. Johnston deserved our award. Technical skill matters, but true healing requires this kind of compassionate, personalized care that recognizes the complex nature of vascular disease.

Looking toward the future, Dr. Johnston believes we’ll increasingly recognize that atherosclerosis manifests from multiple distinct conditions—each requiring tailored interventions.

“I anticipate going forward is that we will begin to understand that atherosclerosis, the formation of plaque is a secondary endpoint for many different diseases,” she explains. “Patients with insulin resistance, diabetes, metabolic syndrome have one phenotype that leads to plaque. Smokers have a separate phenotype. Patients with autoimmune disease, that is a different inflammatory problem that leads to plaque.” By identifying these different “root cause phenotypes” and developing specific strategies for each, we can provide more effective treatment. At the same time, she emphasizes that her approach builds upon—rather than replaces—guideline-directed therapy: “Nothing I do replaces the guideline-directed therapy. We have to build upon the foundation if it’s not enough.”

As someone who talks to PAD patients every day, I see the immediate value in Dr. Johnston’s approach. Patients desperately want clinicians who will listen and help them understand the root causes of their disease. If you’re treating PAD patients, even if you can’t provide comprehensive metabolic assessments yourself, having educational materials and appropriate referral pathways can make a tremendous difference in outcomes. As Dr. Johnston suggests, even developing “some resources for patients to hand out” can streamline care in a busy practice.

Dr. Lily Johnston exemplifies what we look for in our Global PAD Impact Awards: a provider who goes beyond standard care to truly transform how we understand and treat vascular disease. Her integration of advanced diagnostics, targeted nutritional strategies, and conventional therapies is creating personalized protocols that are changing lives—one step at a time.

WATCH THE FULL INTERVIEW WITH DR. LILY JOHNSTON BY CLICKING ON THE IMAGE BELOW:

Kym McNicholas is the Chairman/CEO of the Global PAD Association and host of the Global PAD Impact Awards.

Global PAD Impact Awards - Important Disclaimer Award Clarification and Patient Guidance

The Global PAD Impact Awards are not an endorsement of any award recipient’s medical practice, research, or clinical services. These awards are:

-Based on specific, carefully evaluated criteria

-Nominated by patients who have experienced care

-Selected by a diverse panel including patients, physicians, and clinical experts Important Patient Guidance

Receiving this award does not guarantee that a particular healthcare provider is the right fit for every patient’s unique medical needs. Peripheral Artery Disease (PAD) is a complex condition that requires personalized medical attention.

Choosing the Right Healthcare Provider If you need assistance in selecting a healthcare provider for PAD:

Contact the Global PAD Association’s Leg Saver Hotline at 1-833-PAD-LEGS to speak with experienced professionals who can guide you through the process of finding the most appropriate doctor for your specific presentation of the disease

Remember:

Every patient’s medical journey is unique. Professional consultation is crucial in making informed healthcare decisions.

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