配乐
[ Music ]
TED医学
TED MED
观众掌声
Applause
我永远也忘不了2006年春天的那天
I’ll never forget that day back in the spring of 2006.
我还是约翰霍普金斯医院的一个住院医师
I was a surgical resident at The Johns Hopkins Hospital,
处理求救电话
taking emergency call.
大约凌晨两点左右 我被急诊室叫去
I got paged by the E.R. around 2 in the morning
看一位女病人 她得了糖尿病性足部溃疡
to come and see a woman with a diabetic ulcer on her foot.
我至今记得当我拉开帘子看到她之后
I can still remember sort of that smell of rotting flesh
闻到的那种肉类腐烂的味道
as I pulled the curtain back to see her.
当时所有在场的人都觉得这位女士病得很重
Everybody there agreed this woman was very sick
她需要住院治疗 这是毫无疑问的
and she needed to be in the hospital. That wasn’t being asked.
但我当时考虑的是另一个问题
The question that was being asked of me was a different one,
那就是 她需要截肢吗
which was, did she also need an amputation?
现在 回想起那夜
Now, looking back on that night,
我非常后悔
I’d love so desperately to believe that
那晚面对这位女士时 我心中没有怀着同样的同情和悲悯
I treated that woman on that night with the same empathy and compassion
就像我平时面对其他病人那般 三天前的夜里一位27岁的新娘
I’d shown the 27-year-old newlywed
因为下背部疼痛来到急诊
who came the E.R. three nights earlier with lower back pain
后来被诊断为晚期胰腺癌
that turned out to be advanced pancreatic cancer.
对于她的病况 我知道我无能为力 没办法救她
In her case, I knew there’s nothing I could do that was actually going to save her life.
癌症已经到了晚期
The cancer was too advanced.
但我还是尽我所能的
But I was committed to making sure that
做我可以做的任何事 让她舒服一点
I could do anything possible to make her stay more comfortable.
我帮她找了条毛毯
I brought her a warm blanket
端了杯咖啡 对了 也端给了她的父母
and a cup of coffee, ah, brought some for her parents.
但更重要的是 发现了吗 我不觉得她有错
But more importantly, see, I passed no judgement on her,
因为这种病不是她自己造成的
because obviously she had done nothing to bring this on herself.
但是为什么 仅仅过了几夜
So why was it that, just a few nights later
当我站在同一个急诊室并且决定
as I stood at that same E.R. and determined that
我的糖尿病病人需要截肢的时候
my diabetic patient did indeed need an amputation.
为什么（对她）我的心中带着鄙夷呢？
Why did I hold her in such bitter contempt?
你看 并不像之前的那位新娘
You see, unlike the woman the night before,
这位女士有二型糖尿病
this woman had type 2 diabetes.
她很胖 而且我们都知道肥胖源自
She was fat. And we all know that’s from
吃太多而且缺乏运动 对吧？
eating too much and not exercise enough, right?
我的意思是 节食和运动很难吗
I mean, how hard can it be?
我看着她躺在床上 我心说
As I looked down at her in the bed, I thought to myself,
哪怕你稍微注意一点你的身体
if you just tried caring even a little bit
你也绝不会落到这步田地
you wouldn’t be in this situation, at this moment
和一个即将给你截肢的陌生医生在一起
with some doctor you’ve never met about to amputate your foot.
为什么我能心安理得地责备她呢？
Why did I feel justified in judging her?
我只想说我不知道
I’d like to say I don’t know.
但是说真的 我知道
But I actually do.
你看 我那时年少轻狂
You see, in the hubris of my youth,
我自以为是的觉得
I thought I had her all figured out.
她饮食无度 她运气不好 她得了糖尿病 基本就是这样
She ate too much. She got unlucky. She got diabetes. Case closed.
讽刺的是 就在那会儿 我正在参与癌症的研究
Ironically, at that time in my life, I was also doing cancer research,
确切的来说 黑色素瘤的免疫治疗法
immune-based therapies for melanoma, to be specific,
在那个领域 我学会质疑一切
and in that world I was actually taught to question everything,
挑战一切固有的理论 并且严格遵守最高的科研准则
to challenge all assumptions and hold them to the highest possible scientific standards.
然而当我面对糖尿病
Yet when it came to a disease like diabetes
这种死亡率高于黑色素瘤八倍的疾病时
that kills Americans 8 times more frequently than melanoma.
我从未质疑过传统的理论
I never once questioned the conventional wisdom.
我当时真的认为糖尿病的发病机制早有定论
I actually just assumed the pathologic sequence of events was settled science.
三年以后 我发现我错了
Three years later, I found out how wrong I was.
但是这次 我自己成了病人
But this time, I was the patient.
尽管我每天运动三四个小时
Despite exercising 3 or 4 hours every single day,
严格遵循健康食谱
and following the food pyramid to the letter,
我还是体重激增 并且得了
I’d gained a lot of weight and developed something called
代谢综合征
metabolic syndrome.
你们也许有人听说过它
Some of you may have heard of this.
我产生了胰岛素抗性
I had become insulin resistant.
你们可以把胰岛素当成一种激素
You can think of insulin as this master hormone
它能控制我们的身体对摄入的食物做出反应
that controls what our body does with the foods we eat,
消耗或是储存它们
whether we burn it or store it.
在术语中叫做燃料分区
This is called fuel partitioning in the lingo.
缺乏足够的胰岛素会危及生命
Now failure to produce enough insulin is incompatible with life.
胰岛素抗性 就像字面上意思一样
And insulin resistance, as its name suggests,
意味着你的细胞越来越不受
is when your cells get increasingly resistant to the effect
胰岛素的正常指挥
of insulin trying to do its job.
一旦你出现胰岛素抵抗
Once you’re insulin-resistant,
你离得糖尿病也不远了 也就是
you’re on your way to getting diabetes, which is what happens
因为胰岛素抵抗的缘故 你的胰岛素不够用了
when your pancreas can’t keep up with the resistance and make enough insulin.
你的血糖开始升高
Now your blood sugar levels start to rise,
一系列的病理症状
and an entire cascade of pathological events,
会突然爆发 并且可能导致心脏病
sort of spirals out of control that can lead to heart disease,
癌症 甚至老年痴呆症
cancer, even Alzheimer’s disease,
和截肢 就像几年前那位女士一样
and amputations, just like that woman a few years earlier.
我很害怕 我很快彻底地改了食谱
With that scare, I got busy changing my diet radically,
做了一些让大家觉得
adding and subtracting things most of you would find
不可思议的改变
almost assuredly shocking.
得益于新的食谱 尽管我锻炼少了 我还是减掉了40磅
I did this and lost 40 pounds, weirdly while exercising less.
你们可以看到 我现在没有超重
I, as you can see, I guess I’m not overweight any more.
更重要的是 我没有胰岛素抗性
More importantly, I don’t have insulin resistance.
但最重要的是 我一直被三个亟待解决的问题
But most important, I was left with these three burning questions
困扰着
that wouldn’t go away:
为什么这件事发生在我身上呢 我已经做到无懈可击了
How did this happen to me if I was supposedly doing everything right?
如果传统的营养理论在我身上失效了
If the conventional wisdom about nutrition had failed me,
那在其他人身上呢
was it possible that it’s failing someone else?
通过对这些问题的思考
And underlying these questions,
我着了魔一样 希望找到
I became almost maniacally obsessed in trying to understand
肥胖症和胰岛素抗性的真正关系
the real relationship between obesity and insulin resistance.
现在 主流观点认为
Now, most researchers believe
肥胖症导致了胰岛素抗性
obesity is the cause of insulin resistance.
按逻辑来说 如果你想治疗胰岛素抵抗 你必须先减肥 对吧
Logically, then, if you want to treat insulin resistance, you got people to lose weight, right?
先治疗肥胖症
You treat the obesity.
但如果我们反过来想一下
But what if we have it backwards?
假如肥胖症并不会导致胰岛素抵抗呢？
What if obesity isn’t the cause of insulin resistance at all?
如果它是一个更深层次问题的表现呢？
In fact, what if it’s the symptom of a much deeper problem
显露出来的可能只是冰山一角？
the tip of a proverbial iceberg?
我知道这听起来很疯狂 因为很明显我们正处在一个肥胖的时代
I know it sounds crazy because we’re obviously in the midst of an obesity epidemic,
不过请听我解释
but hear me out.
如果肥胖症只是某种反应机制 用来对付更加凶险的
What if obesity is a coping mechanism for a far more sinister problem
潜藏在细胞深处的问题
going on underneath the cell?
我不是说肥胖是无害的
I’m not suggesting that obesity is benign,
我是说肥胖症只是两种代谢疾病中相对较轻的
but what I am suggesting is it may be the lesser of two metabolic evils.
你可以把胰岛素抵抗看做 降低我们细胞
You can think of insulin resistance as the reduced capacity of our cells
对于燃料的储存能力 就像我之前假设的一样
to partition fuel, as I alluded to a moment ago,
正常情况下我们摄入的能量 一些会被消耗
taking those calories that we take in and burning some appropriately
一些会被储存
and storing some appropriately.
当我们变得胰岛素抵抗时 这个平衡就会偏离
When we become insulin resistant, the homeostasis in that balance deviates
正常状态
from this state.
于是 当胰岛素告诉细胞
So now, when insulin says to a cell,
我需要你消耗更多能量
I want you to burn more energy
如果细胞觉得消耗太多了 那些细胞就会回应到
then the cell considers safe, the cell, in effect, says,
不 谢谢 我更想储存这些能量
“No, thanks, I’d actually rather store this energy.”
因为脂肪细胞不像其他细胞有那么多复杂的细胞器
And because fat cells are actually missing most of complex cellular machinery found in other cells,
这可能是最适合储存脂肪的地方
it’s probably the safest place to store it.
所以 对我们大多数人 大约7500万美国人来说
So, for many of us, about 75 million Americans,
胰岛素抗性应该被看作
the appropriate response to insulin resistance
肥胖的成因 而不是相反的
may actually be to store it as fat, not the reverse,
把胰岛素抵抗归因于肥胖
getting insulin resistance in response to getting fat.
这是个相当微妙的区别
This is a really subtle distinction,
但它的含义却是深刻的
but the implication could be profound.
举个例子来说
Consider the following analogy:
想象一下你小腿上的淤青
Think of the bruise you get on your shin
当你不小心撞上咖啡桌时
when you inadvertently bang your leg into the coffee table.
毫无疑问 这淤青很疼 而且你不喜欢它的颜色
Sure, the bruise hurts like hell and you almost certainly don’t like the discolored look,
但是我们都知道 淤青本身并不是问题
but we all know the bruise per Se is not the problem.
实际上 恰恰相反 这是对外伤的一个正常反应
In fact, it’s the opposite. It’s a healthy response to the trauma,
所有的免疫细胞都会迅速聚集到损伤部位
all of those immune cells rushing to the site of the injury
清理坏死细胞的碎片 并且防止感染扩散到身体其他部位
to salvage the cellular debris and prevent the spread of infection to elsewhere in the body.
好了 想象一下我们把淤青当作问题
Now, imagine we thought bruises were the problem,
我们发展出庞大的医疗体系和文化来治疗淤青
and we evolved a giant medical establishment and a culture around treating bruises:
遮瑕膏 止疼药 等等
masking creams, pain killers, you name it,
而所有一切都忽略了一个事实 那就是人们依然会撞到咖啡桌
all the while ignoring the fact that people are still banging their shins into coffee tables.
如果我们可以从问题的根源入手
How much better would we be if we treated the cause —
告诉人们从客厅走过的时候多注意咖啡桌
telling people to pay attention when they walk through the living room
这会比处理淤青有效果的多
— rather than the effect?
正确理解事情的因果 将会使世界产生巨大的不同
Getting the cause and the effect right makes all the difference in the world.
而治标不治本 制药行业依旧
Getting it wrong, and the pharmaceutical industry can still do
能够为股东带来利润
very well for its shareholders
但对于受伤的人来说 这没有任何帮助
but nothing improves for the people with bruised shins.
原因和结果
Cause and effect.
所以我想指出的是 可能我们把原因和结果
So what I’m suggesting is maybe we have the cause and effect
弄反了 当我们讨论肥胖症和胰岛素抵抗的时候
wrong on obesity and insulin resistance.
也许我们需要问问自己
Maybe we should be asking ourselves
有没有可能胰岛素抗性导致了体重增加
is it possible that insulin resistance causes weight gain
以及肥胖症带来的并发症 至少对大多数人来说
and diseases that associated with obesity, at least in most people?
有没有可能肥胖是一些更深层次问题的代谢反应
What if being obese is just a metabolic response to something much more threatening,
一种潜在的流行病 那才是我们正在应该担心的
an underlying epidemic, the one we ought to be worried about?
让我们看一些暗示性的事实
Let’s look at some suggestive facts.
我们知道美国有三千万肥胖症患者
We know that 30 million obese Americans in the United States
他们没有产生胰岛素抗性
don’t have insulin resistance.
而且没有证据表明他们比瘦的人更容易得病
And by the way, they don’t appear to be at any greater risk of disease than lean people.
恰恰相反 美国有6百万非肥胖症患者
Conversely, we know that 6 million lean people in the United States
产生了胰岛素抗性
are insulin resistant,
而且他们被证实更容易患代谢性疾病
and by the way, they appear to be at even greater risk for those metabolic diseases
就是我之前提到过的
I mentioned a moment ago,
同时几率比肥胖人士要高得多
than their obese counterparts.
虽然我现在不知道为什么 但一个可能的原因是 对他们来说
Now, I don’t know why, but it might be because, in their case,
他们的细胞无法正确的对体内多余的能量做出反应
their cells haven’t actually figured out the right thing to do with that excess energy.
所以 你可以是肥胖症患者 并且没有胰岛素抗性
So, if you can be obese and not have insulin resistance,
或者你可以很瘦 却有胰岛素抗性
and you can be lean and have it,
这表明肥胖只不过是表象（胰岛素抗性才是根源）
this suggests obesity may just be a proxy for what’s going on.
所以如果我们斗争搞错了对象
So, what if we’re fighting the wrong war,
我们一直在与肥胖症对抗 而不是胰岛素抗性
fighting obesity, rather than insulin resistance?
而且更糟的是 如果指责过胖的人 其实却是在指责胰岛素抵抗患者
Even worse, what if blaming the obese means we’re blaming the victims?
如果我们对于肥胖症的一些基本认识就是错的呢？
What if some of our fundamental ideas about obesity are just wrong?
就我个人来说 我不能再继续保持傲慢的态度
Personally, I can’t afford the luxury of arrogance anymore,
让我把那种笃定的确信感丢一边
let alone the luxury of certainty.
对于这些问题的核心 我有自己的想法
I have my own ideas about what could be at the heart of this,
同时 我也愿意与他人分享
but, I’m, I’m wide open to others.
我的假设是这样的 因为老有人问我
Now my hypothesis, because everybody always asks me, is this.
如果你问自己 是什么导致细胞变得胰岛素抵抗呢
If you ask yourself, what’s a cell trying to protect itself from when it becomes insulin resistant,
答案或许不是摄入过多的食物
the answer probably isn’t too much food.
而是摄入过量葡萄糖导致血糖过高
It’s more likely too much glucose: blood sugar.
精制的谷物和淀粉将会升高你的血糖
Now, we know that refined grains and starches elevate your blood sugar
在短时间内 而且我们有理由相信糖分
in the short run, and there’s even reason to believe that sugar may
直接导致胰岛素抵抗症
lead to insulin resistance directly.
所以如果把这些生理过程也列入考虑
So if you kinda put these physiological processes to work,
我认为是大量的摄入
I’d hypothesize that it might be our increased intake of
精制谷物 糖类以及淀粉导致了
refined grains, sugars and starches that’s driving this epidemic
肥胖症和胰岛素耐性 不 是肥胖症和糖尿病的盛行
of obesity and insulin resistance, sorry obesity and diabetes,
但其病因是胰岛素耐性 而不是由于
but through insulin resistance, you see, and not necessarily through just
暴饮暴食和缺乏运动
overeating and under-exercising.
在我几年前减去40磅时
Now, when I lost my 40 pounds a few years ago,
我只是简单了限制了这些东西（精制谷物，糖和淀粉）的摄入
I did it simply by restricting those things,
诚然这也表明我存在一些偏见 而这些主要源自于我的个人经验
which admittedly suggests I have a bias based on my personal experience.
但是这并不意味着我的偏见是错误的
But that doesn’t mean my bias is wrong,
更重要的是 所有这些偏见都可以被科学验证
and most important, all of this can be tested scientifically.
但是第一步就是要接受一种可能性 就是我们对于
But step one is accepting the possibility that our current beliefs
肥胖症 糖尿病和胰岛素抵抗症的理解
about obesity, diabetes and insulin resistance,
可能存在偏差 所以需要被验证
could be wrong and therefore must be tested.
我把我的事业都赌在这个可能性上
I’m betting my career on this.
现在我把所有的时间都花在这个问题的研究上
Today, I devote all of my time to working on this problem,
而且我将在科学的道路上不断探索
and I’ll go wherever the science takes me.
我已经决定有一件事是我不能也不会再做的
I’ve decided that what I can’t and won’t do anymore
就是不懂装懂
is pretend I have the answers when I don’t.
对于我不知道的事 我都非常谦虚
I’ve been humbled enough by all I don’t know.
在过去的一年里 我很幸运
For the past year, I’ve been fortunate enough to work on this problem
可以和国内最优秀的糖尿病和肥胖症专家团队一起研究
with the most amazing team of diabetes and obesity researchers in the country,
最好的事情莫过于 就像亚伯拉罕•林肯将自己置身于由对手组成的团队中
and the best part is, just like Abraham Lincoln surrounded himself with a team of rivals,
我们也做了一样的事情
we’ve done the same thing.
我们找来了另一个科学团队作为竞争对手
We’ve recruited a team of scientific rivals,
他们也都是极为优秀的科学家
the best and brightest who all have different hypotheses
但却对这个流行病的核心有着不同的假设
for what’s at the heart of the epidemic
有一些认为是过量的卡路里摄入 有一些认为是
Some think it’s too many calories consumed. Others think it’s
过量的卡路里摄入 也有人认为是过量的精制谷物和淀粉摄入
too much dietary fat. Others think it’s too many refined grains and starches.
但这个由多学科 具有高度怀疑精神
But this team of multi-disciplinary, highly skeptical
以及相当聪明的研究者至少同意两件事情
and exceedingly talented researchers do agree on two things.
其一 这个问题相当重要 以至于我们不能视而不见
First, this problem is just simply too important to continue ignoring
而假装我们知道答案
because we think we know the answer.
其次 如果我们愿意犯错
And two, if we are willing to be wrong,
如果我们愿意挑战传统观念
if we’re willing to challenge the conventional wisdom,
通过科学实验
with the best experiments science can offer,
我们终将解决这个问题
we can solve this problem.
我知道我们都希望现在就能得到一个答案
I know it’s tempting to want an answer right now,
一些可以参照的行为或者规则
some form of action or policy,
一些饮食处方 告诉我们该吃什么 不该吃什么
some dietary prescription–eat this, not that–
但是如果我们想找到一个正确的答案
but if we want to get it right,
我们就必须进行严谨的科学尝试
we’re going to have to do much more rigorous science
不然我们无法写出这个处方
before we can write that prescription.
简而言之 为了解决这个问题 我们的研究项目主要围绕着3个方面
Briefly, to address this, our research program is focused around three meta-themes,
或者问题展开 首先我们摄入的各种各样的食物是如何影响
or questions, first, how do the various foods we consume impact
我们的代谢 激素和酶的
our metabolism, hormones and enzymes,
并且是通过什么细微的分子机制发生的
and through what nuanced molecular mechanisms?
第二 基于这个视角
Second, based on these insights,
人们能不能对他们的饮食做出必要的调整
can people make the necessary changes in their diets
使它更安全更易实践
that in a safe and practical way to implement?
最终 一旦我们找到既安全且更易实践 可以应用到
And finally, once we identify what safe and practical changes people can make
饮食中的方法 我们又如何改变他们的习惯
to their diet, how can we move their behavior
使之变得更为自然
in that direction so that it becomes more the default
而不是一种刻意行为
rather than the exception?
你看 如果你仔细想几分钟
You see, if you think about it for a moment,
（就会发现）这在昨天就已经涉及到了
and this was touched on last night.
因为你知道怎么做并不意味着 你可以坚持这么做
Just because you know what to do doesn’t mean you’re always going to do it.
有时我们不得不给人一些诱因 使这种坚持变得简单
Sometimes we have to put cues around people to make it easier,
不管你信不信 这都可以经过科学研究
and believe it or not, that can be studied scientifically.
我不知道这个研究最终将会带我去向何处
I don’t know how this journey is going to end, but
但对我而言 至少有一点是可以肯定的
but this much seems clear to me at least
我们不能像我曾经那样指责肥胖症和糖尿病患者
We can’t keep blaming our overweight and diabetic patients like I did.
他们中的绝大部分其实都想做正确的选择
Most of them actually want to do the right thing,
但前提是知道什么是正确的
but they have to know what that is,
而且它们切实可行
and it’s got to work.
我梦想有一天当我们的患者可以
I dream of a day when our patients can, you know,
减去多余的重量 治好胰岛素抵抗
shed their excess pounds and cure themselves of insulin resistance,
因为作为医学专家
because as medical professionals,
我们已经抛开了多余的思想包袱
we’ve shed our excess mental baggage,
并且不再抵抗新观点
and cured ourselves of new idea resistance
从而使我们回归最初的想法
sufficiently to go back to our original ideas:
开放的思维 抛弃那些过时的观点的勇气
open minds, the courage to throw out yesterday’s ideas
当这些观点已经不再有效时
when they don’t appear to be working,
相信科学的真理没有终点 只有不断的进化
and the understanding that scientific truth isn’t final, but constantly evolving.
一直在追求真理的道路上坚持 对患者和科学来说都会更好
Staying true to that path will be better for our patients and better for science.
如果肥胖不再是代谢疾病的替罪羊
If obesity is nothing more than a proxy for metabolic illness,
那么我们去指责这些替罪羊又有什么好处呢
what good does it do us to punish those with the proxy?
我有时会回想七年前急救室的那个夜晚
Sometimes I think back to that night in the E.R. seven years ago,
我希望我可以再和那位女士聊聊
I wish I could speak with that woman again.
我想向她道歉
I’d like to tell her how sorry I am.
我想说 作为一个医生 我提供了我所能提供的最好治疗
I’d say, you know as a doctor, I delivered the best clinical care I could,
哽咽
Pause
但是作为一个人 我让你失望了
but as a human being, I let you down.
你需要的不是我的审判和我的鄙视
Uh, you didn’t need my judgement and my contempt.
你需要我的同情和怜悯
You needed my empathy and compassion,
而且无论如何 你需要一个医生 愿意相信
above all else, you needed a doctor who was willing to consider
或许你没有辜负我们的医疗系统
maybe you didn’t let the system down.
也许是这个包括我在内的医学系统
Maybe the system, of which I was a part,
辜负了你
was letting you down.
如果你正好在看这个演讲
If you’re watching this now,
我希望你能原谅我
I hope you can forgive me.
观众掌声
Applause
TED医学
TED MED