[ Music ]
I’ll never forget that day back in the spring of 2006.
I was a surgical resident at The Johns Hopkins Hospital,
taking emergency call.
I got paged by the E.R. around 2 in the morning
to come and see a woman with a diabetic ulcer on her foot.
I can still remember sort of that smell of rotting flesh
as I pulled the curtain back to see her.
Everybody there agreed this woman was very sick
and she needed to be in the hospital. That wasn’t being asked.
The question that was being asked of me was a different one,
which was, did she also need an amputation?
Now, looking back on that night,
I’d love so desperately to believe that
I treated that woman on that night with the same empathy and compassion
I’d shown the 27-year-old newlywed
who came the E.R. three nights earlier with lower back pain
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.
The cancer was too advanced.
But I was committed to making sure that
I could do anything possible to make her stay more comfortable.
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,
because obviously she had done nothing to bring this on herself.
So why was it that, just a few nights later
as I stood at that same E.R. and determined that
my diabetic patient did indeed need an amputation.
Why did I hold her in such bitter contempt?
You see, unlike the woman the night before,
this woman had type 2 diabetes.
She was fat. And we all know that’s from
eating too much and not exercise enough, right?
I mean, how hard can it be?
As I looked down at her in the bed, I thought to myself,
if you just tried caring even a little bit
you wouldn’t be in this situation, at this moment
with some doctor you’ve never met about to amputate your foot.
Why did I feel justified in judging her?
I’d like to say I don’t know.
But I actually do.
You see, in the hubris of my youth,
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,
immune-based therapies for melanoma, to be specific,
and in that world I was actually taught to question everything,
to challenge all assumptions and hold them to the highest possible scientific standards.
Yet when it came to a disease like diabetes
that kills Americans 8 times more frequently than melanoma.
I never once questioned the conventional wisdom.
I actually just assumed the pathologic sequence of events was settled science.
Three years later, I found out how wrong I was.
But this time, I was the patient.
Despite exercising 3 or 4 hours every single day,
and following the food pyramid to the letter,
I’d gained a lot of weight and developed something called
Some of you may have heard of this.
I had become insulin resistant.
You can think of insulin as this master hormone
that controls what our body does with the foods we eat,
whether we burn it or store it.
This is called fuel partitioning in the lingo.
Now failure to produce enough insulin is incompatible with life.
And insulin resistance, as its name suggests,
is when your cells get increasingly resistant to the effect
of insulin trying to do its job.
Once you’re insulin-resistant,
you’re on your way to getting diabetes, which is what happens
when your pancreas can’t keep up with the resistance and make enough insulin.
Now your blood sugar levels start to rise,
and an entire cascade of pathological events,
sort of spirals out of control that can lead to heart disease,
cancer, even Alzheimer’s disease,
and amputations, just like that woman a few years earlier.
With that scare, I got busy changing my diet radically,
adding and subtracting things most of you would find
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.
I, as you can see, I guess I’m not overweight any more.
More importantly, I don’t have insulin resistance.
But most important, I was left with these three burning questions
that wouldn’t go away:
How did this happen to me if I was supposedly doing everything right?
If the conventional wisdom about nutrition had failed me,
was it possible that it’s failing someone else?
And underlying these questions,
I became almost maniacally obsessed in trying to understand
the real relationship between obesity and insulin resistance.
Now, most researchers believe
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?
You treat the obesity.
But what if we have it backwards?
What if obesity isn’t the cause of insulin resistance at all?
In fact, what if it’s the symptom of a much deeper problem
the tip of a proverbial iceberg?
I know it sounds crazy because we’re obviously in the midst of an obesity epidemic,
but hear me out.
What if obesity is a coping mechanism for a far more sinister problem
going on underneath the cell?
I’m not suggesting that obesity is benign,
but what I am suggesting is it may be the lesser of two metabolic evils.
You can think of insulin resistance as the reduced capacity of our cells
to partition fuel, as I alluded to a moment ago,
taking those calories that we take in and burning some appropriately
and storing some appropriately.
When we become insulin resistant, the homeostasis in that balance deviates
from this state.
So now, when insulin says to a cell,
I want you to burn more energy
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.”
And because fat cells are actually missing most of complex cellular machinery found in other cells,
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,
the appropriate response to insulin resistance
may actually be to store it as fat, not the reverse,
getting insulin resistance in response to getting fat.
This is a really subtle distinction,
but the implication could be profound.
Consider the following analogy:
Think of the bruise you get on your shin
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,
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,
all of those immune cells rushing to the site of the injury
to salvage the cellular debris and prevent the spread of infection to elsewhere in the body.
Now, imagine we thought bruises were the problem,
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,
all the while ignoring the fact that people are still banging their shins into coffee tables.
How much better would we be if we treated the cause —
telling people to pay attention when they walk through the living room
— rather than the effect?
Getting the cause and the effect right makes all the difference in the world.
Getting it wrong, and the pharmaceutical industry can still do
very well for its shareholders
but nothing improves for the people with bruised shins.
Cause and effect.
So what I’m suggesting is maybe we have the cause and effect
wrong on obesity and insulin resistance.
Maybe we should be asking ourselves
is it possible that insulin resistance causes weight gain
and diseases that associated with obesity, at least in most people?
What if being obese is just a metabolic response to something much more threatening,
an underlying epidemic, the one we ought to be worried about?
Let’s look at some suggestive facts.
We know that 30 million obese Americans in the United States
don’t have insulin resistance.
And by the way, they don’t appear to be at any greater risk of disease than lean people.
Conversely, we know that 6 million lean people in the United States
are insulin resistant,
and by the way, they appear to be at even greater risk for those metabolic diseases
I mentioned a moment ago,
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,
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,
and you can be lean and have it,
this suggests obesity may just be a proxy for what’s going on.
So, what if we’re fighting the wrong war,
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?
What if some of our fundamental ideas about obesity are just wrong?
Personally, I can’t afford the luxury of arrogance anymore,
let alone the luxury of certainty.
I have my own ideas about what could be at the heart of this,
but, I’m, I’m wide open to others.
Now my hypothesis, because everybody always asks me, is this.
If you ask yourself, what’s a cell trying to protect itself from when it becomes insulin resistant,
the answer probably isn’t too much food.
It’s more likely too much glucose: blood sugar.
Now, we know that refined grains and starches elevate your blood sugar
in the short run, and there’s even reason to believe that sugar may
lead to insulin resistance directly.
So if you kinda put these physiological processes to work,
I’d hypothesize that it might be our increased intake of
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,
but through insulin resistance, you see, and not necessarily through just
overeating and under-exercising.
Now, when I lost my 40 pounds a few years ago,
I did it simply by restricting those things,
which admittedly suggests I have a bias based on my personal experience.
But that doesn’t mean my bias is wrong,
and most important, all of this can be tested scientifically.
But step one is accepting the possibility that our current beliefs
about obesity, diabetes and insulin resistance,
could be wrong and therefore must be tested.
I’m betting my career on this.
Today, I devote all of my time to working on this problem,
and I’ll go wherever the science takes me.
I’ve decided that what I can’t and won’t do anymore
is pretend I have the answers when I don’t.
I’ve been humbled enough by all I don’t know.
For the past year, I’ve been fortunate enough to work on this problem
with the most amazing team of diabetes and obesity researchers in the country,
and the best part is, just like Abraham Lincoln surrounded himself with a team of rivals,
we’ve done the same thing.
We’ve recruited a team of scientific rivals,
the best and brightest who all have different hypotheses
for what’s at the heart of the epidemic
Some think it’s too many calories consumed. Others think it’s
too much dietary fat. Others think it’s too many refined grains and starches.
But this team of multi-disciplinary, highly skeptical
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
because we think we know the answer.
And two, if we are willing to be wrong,
if we’re willing to challenge the conventional wisdom,
with the best experiments science can offer,
we can solve this problem.
I know it’s tempting to want an answer right now,
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–
but if we want to get it right,
we’re going to have to do much more rigorous science
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,
or questions, first, how do the various foods we consume impact
our metabolism, hormones and enzymes,
and through what nuanced molecular mechanisms?
Second, based on these insights,
can people make the necessary changes in their diets
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
to their diet, how can we move their behavior
in that direction so that it becomes more the default
rather than the exception?
You see, if you think about it for a moment,
and this was touched on last night.
Just because you know what to do doesn’t mean you’re always going to do it.
Sometimes we have to put cues around people to make it easier,
and believe it or not, that can be studied scientifically.
I don’t know how this journey is going to end, but
but this much seems clear to me at least
We can’t keep blaming our overweight and diabetic patients like I did.
Most of them actually want to do the right thing,
but they have to know what that is,
and it’s got to work.
I dream of a day when our patients can, you know,
shed their excess pounds and cure themselves of insulin resistance,
because as medical professionals,
we’ve shed our excess mental baggage,
and cured ourselves of new idea resistance
sufficiently to go back to our original ideas:
open minds, the courage to throw out yesterday’s ideas
when they don’t appear to be working,
and the understanding that scientific truth isn’t final, but constantly evolving.
Staying true to that path will be better for our patients and better for science.
If obesity is nothing more than a proxy for metabolic illness,
what good does it do us to punish those with the proxy?
Sometimes I think back to that night in the E.R. seven years ago,
I wish I could speak with that woman again.
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,
but as a human being, I let you down.
Uh, you didn’t need my judgement and my contempt.
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
maybe you didn’t let the system down.
Maybe the system, of which I was a part,
was letting you down.
If you’re watching this now,
I hope you can forgive me.