‘Save Legs, Change Lives’ confronts amputation-causing PAD

Heart disease and other heart conditions, cancer, strokes and COVID-19 have all done major damage to Black lives, with heart issues leading the way. Cardiovascular disease is the number one killer of Americans, but there is one type that many in local and national Black communities have never heard of.

It’s peripheral artery disease. And it’s not only taking lives, it’s taking limbs, as well, in the form of amputations befalling Blacks at alarming rates. And what makes PAD even more dangerous is the fact that it is grossly under-diagnosed and under-treated.

April 13 – 17 has brought the Bayou City an initiative that seeks to not only increase the Black community’s awareness of PAD, but offer screenings so people can learn their status.

“Save Legs. Change Lives.™ Spot Peripheral Artery Disease Now” is a multi-year initiative creating urgency and action to help address the hidden threat of PAD-related amputation, particularly among African Americans, who are up to four times more likely than other Americans to have a PAD-related amputation. Disproportionate rates of PAD-related amputation are a result of Black Americans being twice as likely to have PAD, with less access to quality vascular care and greater risk for delays in care.

MAPS SHOW HIGHEST AMPUTEE RATES GEOGRAPHICALLY IN PLACES WHERE MAJORITY OF TODAY’S BLACK POPULATION LIVES, MIMICS LOCATION OF LARGEST ENSLAVED POPULATIONS OF 1860

SLCL, an initiative that’s a part of Johnson & Johnson’s broader commitment to help eradicate racial and social injustice as a public health threat, seeks to 1) empower individuals and communities to change the trajectory of their health, 2) collaborate with partners to break down barriers to equitable care and 3) drive research that uncovers systemic bias and patient needs to propel change.

What that looks like in Houston current reality is five days dedicated to increasing the number of Black people who are screened for PAD. Here’s the list of sites where screenings have been and will be offered:

Date	Location	Time
Thursday, April 13	JW Peavy Senior Center 3814 Market St. Houston, Texas 77020	9 a.m.–4 p.m.
Friday April 14	Acres Homes Multi-Service Center 6719 W. Montgomery Rd. Houston, Texas 77091	9 a.m.–4 p.m.
Saturday, April 15	The Walk to Save Black Men’s Lives Texas Southern University 3100 Cleburne St. Houston, Texas 77004	7 a.m.–12 p.m.
Sunday, April 16	Fifth Ward Church of Christ 4308 Stonewall St. Houston, Texas 77020	7 a.m.–9 a.m. / 12:30 p.m.–5 p.m.
Monday, April 17	Fifth Ward Church of Christ 4308 Stonewall St. Houston, Texas 77020	9 a.m.–4 p.m.

To help readers better comprehend the seriousness of PAD, the Defender spoke with Dr. Naddi Marah, who specializes in dealing with this issue.

DEFENDER: Dr. Marah, can you introduce yourself to the Defender faithful?

MARAH: I’m a cardiologist and an interventional cardiologist serving the Houston community. I practiced in Humble and in Woodlands, Texas. I’m a Houston native. I graduated from high school in southwest Houston, from Alief Elsik High School. I did my undergraduate studies in French, believe it or not, as well as biology, at the University of Texas at Austin.

DISTURBING FACT: Several studies have reported minority patients are much less likely to receive preventive vascular screenings and procedures. [Source: “Disparities in Amputations in Minorities” by Kristin M. Lefebvre, PT, PhD, CCS and Lawrence A. Lavery, DPM, MPH]

DEFENDER: Can you explain what exactly is peripheral artery disease?

DR. NADDI MARAH: So, PAD, peripheral artery disease, is a very serious and often underdiagnosed cardiovascular condition. It causes the blood vessels to narrow because of what we call plaque formation. And plaque is a combination of cholesterol, calcium blood clots. It narrows the vessels that supply blood to your limbs. And by doing so, it causes people to have certain symptoms: pain, discomfort, ulcerations and others.

DEFENDER: Why is there so little general public awareness about PAD?

MARAH: In the cardiovascular community, we take pride in treating a variety of conditions. I do that myself. Coronary disease, heart attacks, strokes, things like heart failure, things like arrhythmias. These things are well known because it seems to happen every single day, every single night. That’s what we are on call for; to run to the hospital to fix these types of conditions. PAD, affecting the legs more than any other parts of the body, goes undiagnosed and overlooked, because the symptoms sometimes are none. Statistics show that up to 40% of people don’t have any signs or symptoms of having PAD. And those who do have signs, we tend to say it’s because of something else, because of aging, because of having arthritis or bone issues. So, unfortunately, it goes overlooked. And as a consequence, the statistics demonstrate that it’s not well-treated or not well understood in the communities.

DISTURBING FACT: In the case of peripheral arterial disease, minorities are less likely to have limb-sparing procedures such as angioplasty and lower extremity bypass and more likely to have amputation. [Source: “Disparities in Amputations in Minorities” by Kristin M. Lefebvre, PT, PhD, CCS and Lawrence A. Lavery, DPM, MPH]

DEFENDER: Can I assume PAD hits Black people harder than any other demographic? And if so, why is that?

MARAH: Yeah, that’s very true. PAD affects everyone, but it does affect Black Americans disproportionately more than others. We tend to say, “Well, it’s because of risk factors,” for example, having high blood pressure, having high cholesterol, having diabetes, smoking—you’ll have actually have a four times higher likelihood of developing PAD, especially in Blacks. Now, why do Blacks have it more than others? Genetics do play a role. For some reason, genetically inclined we are to having things like hypertension, another big risk factor for PAD, having things like diabetes, another big risk factor for PAD and having high cholesterol, another big risk factor for PAD.

DEFENDER: During doctor visits, what questions should we be asking to make sure our doctors are looking out for PAD? And do doctors screen for PAD as much as they do other conditions?

MARAH: I’ll tell you this, based on how I practice cardiovascular medicine, when I was training downtown at the Medical Center, I saw a variety of things. I trained in the height of COVID. So, we were doing procedures on patients crashing with lung disease, putting them on bypass machines, and so on and so forth. And we spent a lot of time looking at the heart, the brain, lungs, not so much time looking at the legs. And, as I got into my practice in cardiovascular medicine in the community, I was focused heavily on coronary disease. But I realized that over the last two years, my practice focus has shifted now to PAD. And I’ll tell you why. When people come into our clinics, conventionally, we care about the heart, we care about the brain, we care about heart failure and rhythm issues, like I mentioned. A lot of people don’t take the time per se, not just cardiologists, even general practitioners, to just say, “Hey, take your shoes off. Let’s look at your feet. Let’s check your pulse. Why are you limping today? Why are you walking so slowly coming into my office?” We always have a crunch for time. We have to see patients quickly, see the next person, see the next person. So, rarely did we take the time to look, listen and just ask the right questions.

When you go see your doctor, what I challenge (people) to do is be open, be transparent. Say everything. Don’t just listen to what we (doctors) have to tell you. Tell us what you are concerned about. And our job is to react to your concerns, not just tell you what we think you need to do or what you need to know. Or else we will never get to know that PAD, for example, exists. When somebody comes into my clinic and says, “Hey, I’m having leg pains” or “I’m having certain symptoms, cramping in the leg, discomfort, heaviness, tightness. I have coldness to touch. For example, my leg on the right side is colder to me than my leg on the left side. Oh, I have this blister that’s not getting any better.” Those are signs of PAD. We start asking the right questions. We first ask about your overall medical history. We ask about your risk factor profile. We ask about your family history. We ask about your lifestyle. We ask about your functionality. “How much has changed over the last few months? Do you feel like you used to be able to dance with your wife or with your kids, and now you can barely walk to the mailbox or walk through the mall shopping because you have a pain?” We have to start digging and asking these questions. Then, the screening starts. It starts off with a history, then a physical.

DEFENDER: What specific things should we be expecting our doctor to look at and ask about?

MARAH: We need to look at your feet, we need to look at your limbs, check your pulses, look at your toes. And then we do certain types of testing to understand if you have reductions in blood flow to your legs. I would urge you, there’s a website called www.SaveLegsChangeLives.com.” It gives you a lot of information about screening and things to know about PAD and how we as physicians and yourself as a potential patient can determine if you have underlying PAD and what needs to be done about it.

DISTURBING STAT: Black women 7.6× more likely to undergo amputation when compared with other women and 1.3× more likely when compared with other Blacks. [Source: “Racial differences in operation for peripheral vascular disease: results of a population-based study” by Brothers et al]

DEFENDER: What is it about you or your life experiences that opened you to have this PAD focus?

MARAH: When I graduated and I moved to the north side of town, I realized that there were so many people getting amputations PAD. We grade PAD based on your level of limitation, how much a limb has been affected by ulcerations and wounds and things like that. Well, when I was in training, I saw the mildest of conditions. When I graduated and moved to my community now, I realized that these are the worst of conditions, and these are the people who were getting amputated before getting intervened on by people like us. In short, the rate of amputation is quite high in our communities, especially in the African-American community. And that’s a rhetoric that I am trying to change. And not just me. A variety of other cardiologists in my community are trying to do that. But I have made it my focus over the last two years, seeing the numbers, seeing the way amputations change people’s lifestyle.

These are breadwinners, mothers of families, fathers of families. They have kids in school. They wanna make it to prom. They wanna walk their kids down the aisle for their weddings, and they will never get that opportunity because legs have been amputated, sometimes prematurely, sometimes just because they don’t know that there are other options for them; interventions that can be done to potentially treat limbs. So, I changed my practice because of that.

I grew up in West Africa and Sierra Leone. I came here as a refugee. In my country, we were limited in terms of resources, for our healthcare system. We barely had running water, electricity, let alone Tylenol or any type of medication to help with anything at all. When I came here as a refugee, I realized that there were so many options and so many opportunities, yet and still, there are conditions that affect our communities at a very disproportionate amount, like PAD. Seeing how many people are being affected and knowing that they have options to treat them so they don’t get to that point, made me focus more on PAD and hopefully making a difference.

DEFENDER: What 1-3 things do you want the general public to know about PAD if they don’t learn anything else?

MARAH: PAD is becoming the number one cardiovascular disease nowadays in the United States. It used to be heart failure and heart attacks. And then when COVID came about, everyone said, “Oh, COVID this, COVID that.” No. Cardiovascular conditions, including PAD, is still the number one cause of death. It kills more than cancer. It kills more than stroke. It kills more than COVID. It kills more than other infections. And like I said, it goes underdiagnosed. What we need to know as a community is we need to understand the risk factors for it. These include smoking, the biggest risk factor, hypertension, which is prevalent in the African-American community, high cholesterol, high blood sugar, diabetes. The symptoms to look out for?

Sometimes you don’t have any symptoms. You just have risk factors. But if you have symptoms, symptoms to look out for include things like cramping sensation of the legs, pain, discomfort, discoloration, you’re limping, ulcers and blisters, poor toenail growth. And how do we fix this? There are a variety of ways to do so, but it first starts off with you seeing a specialist or your primary care physician and explaining what symptoms you may have or what risk factors you may have, and getting them to do a thorough physical examination and history taking on you to understand where you fall in terms of risk stratification.

DEFENDER: So, what does prevention look like?

MARAH: As any facet of medicine, we always say prevention is key, and even more so in heart and vascular health. It’s tougher to treat and way easier to prevent. And I tell people this all the time, be more active, quit smoking and take good care of your feet. And most importantly, get checked regularly by your doctor. Now, prevention, you can change your lifestyle. It’s easier said than done. Like I mentioned, we all eat what we like to eat, but I like to tell my patients, everything we do we have to do in moderation. Limit your consumption of things like fatty foods, foods high in cholesterol, foods high in sugars. And if you do so, it helps minimize your risk of getting any type of cardiovascular condition, and especially PAD. And I’m gonna make reference to this once more because I think it’s very, very important: www.SaveLegsChangeLives.com. There’s a lot of information you can find there to understand what PAD is and how we as physicians and patients in the Black and African American community can change this rhetoric.

DISTURBING STAT: Black patients more likely than white or other race amputees to undergo first or repeat amputation. [Source: “Racial differences in primary and repeat lower extremity amputation: results from a multihospital study” by Feinglass et al.]

DEFENDER: Are there ways to manage PAD if diagnosed so a person can avoid amputation?

MARAH: There are several ways to manage it. Believe it or not, even though I’m an interventionalist, which means I do procedures to salvage limbs and make sure people can walk again, which I do almost every single day now, because the numbers are just there, there are many patients waiting to get these things done, I focus on prevention, obviously. But I also do whatever I can to keep you off an operating table. Which means we get very, very aggressive in controlling those risk factors that I mentioned. We get aggressive with blood pressure control, giving you small medications to help improve those numbers. Bring those numbers down. We give you medications for cholesterol. If your diet, your lifestyle, your exercise hasn’t modified that enough, we give you medications for blood sugar, diabetes. We even give you medications for smoking cessation. And a lot of counseling goes along with that. If we’ve tried medicines and medicines haven’t worked, then yes, there are options that your specialist can talk to you about in terms of how to go about fixing PAD from an intervention standpoint. And believe it or not, most of it is pretty straightforward.