Peter Attia: What if we're wrong about diabetes?

Translator: Joseph Geni Reviewer: Morton Bast

翻译人员: Weichen Cai 校对人员: Shengwei Cai

I'll never forget that day

我永远忘不了那天

back in the spring of 2006.

2006年的春天。

I was a surgical resident

我还是一个外科住院医生

at The Johns Hopkins Hospital,

在约翰霍普金斯医院

taking emergency call.

应对急救电话

I got paged by the E.R. around 2 in the morning

大约凌晨两点左右，我被急诊室叫去

to come and see a woman with a diabetic ulcer

看一位女病人，她得了因糖尿病而引起的

on her foot.

足部溃疡。

I can still remember sort of that smell of rotting flesh

我至今还能记得当我拉开帘子看到她之后

as I pulled the curtain back to see her.

闻到的那种肉类腐烂的味道。

And everybody there agreed this woman was very sick

显而易见这位女士病得很重

and she needed to be in the hospital.

她需要住院治疗。

That wasn't being asked.

这是毫无疑问的。

The question that was being asked of me was a different one,

但那时我考虑的是另一个问题

which was, did she also need an amputation?

那就是，她需要截肢吗？

Now, looking back on that night,

现在，回想起那夜，

I'd love so desperately to believe that I treated that woman

我很后悔那天夜里面对那位女士时

on that night with the same empathy and compassion

心中没有带着同样的同情与悲悯

I'd shown the 27-year-old newlywed

就像我平时面对其他病人那般

who came to the E.R. three nights earlier

三天前的夜里一位27岁的新娘

with lower back pain

因为下背疼痛来看急诊

that turned out to be advanced pancreatic cancer.

后来她被诊断为晚期胰腺癌。

In her case, I knew there was nothing I could do

虽然我知道我对她无能为力

that was actually going to save her life.

没办法救她。

The cancer was too advanced.

癌症已经是末期了。

But I was committed to making sure that

但我还是尽我所能的

I could do anything possible to make her stay

做了所有能让她

more comfortable. I brought her a warm blanket

舒服一点的事情。我帮她找了条毛毯

and a cup of a coffee.

端了杯咖啡。

I brought some for her parents.

给她父母送咖啡。

But more importantly, see, I passed no judgment on her,

更重要的是，我一点也不觉得这姑娘有错

because obviously she had done nothing

很明显她对自己的病

to bring this on herself.

一点责任也没有

So why was it that, just a few nights later,

但是为什么，仅仅过了几夜

as I stood in that same E.R. and determined

当我站在同一个急救室并且决定

that my diabetic patient did indeed need an amputation,

我的这位糖尿病病人需要截肢手术时

why did I hold her in such bitter contempt?

为什么我的心中带着蔑视呢？

You see, unlike the woman the night before,

你看，跟那位新娘不一样

this woman had type 2 diabetes.

这位女士有II型糖尿病

She was fat.

她很胖。

And we all know that's from eating too much

而且我们都知道肥胖源自 无节制的饮食和缺乏运动，对吧？

and not exercising enough, right?

而且我们都知道肥胖源自 无节制的饮食和缺乏运动，对吧？

I mean, how hard can it be?

我的意思是，节食和运动很难吗？

As I looked down at her in the bed, I thought to myself,

我看着她躺在床上，我心说

if you just tried caring even a little bit,

哪怕你稍微注意一点儿自己的身体

you wouldn't be in this situation at this moment

你也绝不会落到这步田地

with some doctor you've never met

跟一个即将给你截肢的陌生在一起

about to amputate your foot.

跟一个即将给你截肢的陌生在一起

Why did I feel justified in judging her?

为什么当时我能心安理得的责备她呢？

I'd like to say I don't know.

我希望我不知道原因。

But I actually do.

但是说真的，我知道。

You see, in the hubris of my youth,

你看，我那时年少轻狂

I thought I had her all figured out.

我自以为是的觉得 她肯定就是我想到那样。

She ate too much. She got unlucky.

她饮食无度，她运气不好

She got diabetes. Case closed.

她得了糖尿病，基本就是这个情况。

Ironically, at that time in my life,

讽刺的是，就在那会儿

I was also doing cancer research,

我正在参与癌症的研究

immune-based therapies for melanoma, to be specific,

黑色素瘤的细胞免疫力疗法，具体来说

and in that world I was actually taught to question everything,

在那个领域里，我被教着去质疑一切

to challenge all assumptions

挑战一切固有的理论成果

and hold them to the highest possible scientific standards.

并且在研究中严格遵守最高的科研准则。

Yet when it came to a disease like diabetes

但当我面对糖尿病

that kills Americans eight times more frequently than melanoma,

这种致死几率高于黑色素瘤八倍的疾病时候

I never once questioned the conventional wisdom.

我从未质疑过传统的理论。

I actually just assumed the pathologic sequence of events

我当时真的认为糖尿病的发病机理

was settled science.

早有定论。

Three years later, I found out how wrong I was.

三年以后，我发现我错了。

But this time, I was the patient.

但是这次，我自己成了病人。

Despite exercising three or four hours every single day,

尽管我每天运动三四个小时

and following the food pyramid to the letter,

严格遵守健康食谱

I'd gained a lot of weight and developed something

我还是体重激增并且得了

called metabolic syndrome.

代谢综合征。

Some of you may have heard of this.

你们也许有人听说过它。

I had become insulin-resistant.

我的身体对胰岛素产生了抗性。

You can think of insulin as this master hormone

你们可以把胰岛素想象成一种荷尔蒙

that controls what our body does with the foods we eat,

它能控制我们的身体对摄入的食物做出反应

whether we burn it or store it.

消耗或是储存它们。

This is called fuel partitioning in the lingo.

在术语中称之为燃料分区。

Now failure to produce enough insulin is incompatible with life.

缺乏足够的胰岛素是很要命的。

And insulin resistance, as its name suggests,

胰岛素抵抗，就像字面上意思一样

is when your cells get increasingly resistant

意味着你的细胞变得越来越不受

to the effect of insulin trying to do its job.

胰岛素的指挥正常运作。

Once you're insulin-resistant,

一旦你出现胰岛素抵抗的情况

you're on your way to getting diabetes,

你离患糖尿病就不远了

which is what happens when your pancreas

因为胰岛素抵抗的缘故

can't keep up with the resistance and make enough insulin.

你无法制造足够的胰岛素。

Now your blood sugar levels start to rise,

你的血糖开始升高

and an entire cascade of pathologic events

一系列的病例症状

sort of spirals out of control that can lead to heart disease,

会突然爆发并且可能导致心脏病

cancer, even Alzheimer's disease,

癌症，甚至老年痴呆症

and amputations, just like that woman a few years earlier.

或者截肢，就像几年前的那位女士一样。

With that scare, I got busy changing my diet radically,

我很害怕，我很快改了食谱

adding and subtracting things most of you would find

做了一些让大家觉得

almost assuredly shocking.

不可思议的改变。

I did this and lost 40 pounds, weirdly while exercising less.

得益于新的食谱 尽管我锻炼得少了，我还是减掉了40磅

I, as you can see, I guess I'm not overweight anymore.

你们可以看到，我现在没有超重

More importantly, I don't have insulin resistance.

更重要的是，我没有胰岛素抵抗症了

But most important, I was left

但是最重要的是，我陷入了

with these three burning questions that wouldn't go away:

三个亟待解决的问题

How did this happen to me if I was supposedly

为什么这件事发生在我身上呢?

doing everything right?

我已经尽力做到无懈可击了。

If the conventional wisdom about nutrition had failed me,

如果传统的营养理论在我身上失效了

was it possible it was failing someone else?

在其他人身上会怎样呢？

And underlying these questions,

通过对考虑这些问题

I became almost maniacally obsessed

我着了魔一样的

in trying to understand the real relationship

希望找到肥胖和胰岛素之间

between obesity and insulin resistance.

真正的关系。

Now, most researchers believe obesity

现在，主流观点认为

is the cause of insulin resistance.

肥胖导致了胰岛素抵抗。

Logically, then, if you want to treat insulin resistance,

依逻辑来说，如果你想治疗胰岛素抵抗

you get people to lose weight, right?

你必须减肥，对吧？

You treat the obesity.

先对付肥胖。

But what if we have it backwards?

但是如果我们反过来想一下？

What if obesity isn't the cause of insulin resistance at all?

假如肥胖并不会导致胰岛素抵抗？

In fact, what if it's a symptom of a much deeper problem,

实际上，假如它只是一个征兆

the tip of a proverbial iceberg?

一个更深层次的问题的冰山一角？

I know it sounds crazy because we're obviously in the midst

这听起来很疯狂 因为我们很正身处

of an obesity epidemic, but hear me out.

一个肥胖症泛滥的时代，不过请耐心听我解释。

What if obesity is a coping mechanism

假如肥胖是身体的某种应对机制

for a far more sinister problem going on

用来对付一个潜藏在细胞深处

underneath the cell?

更加凶险的问题？

I'm not suggesting that obesity is benign,

我不认为肥胖是无害的

but what I am suggesting is it may be the lesser

但是我觉得肥胖在两种新陈代谢疾病中

of two metabolic evils.

是比较次要的那个。

You can think of insulin resistance as the reduced capacity

大家可以把胰岛素抵抗症看作

of our cells to partition fuel,

我们身体燃料箱变小了

as I alluded to a moment ago,

就像我刚刚假设的那样

taking those calories that we take in

正常情况下我们摄入的热量

and burning some appropriately and storing some appropriately.

会被适量消耗并且适量储存。

When we become insulin-resistant,

当我们得了胰岛素抵抗的时候

the homeostasis in that balance deviates from this state.

这个平衡就会偏离正常情况。

So now, when insulin says to a cell,

于是乎，当胰岛素告诉细胞

I want you to burn more energy

我需要你消耗一些能量，假如

than the cell considers safe, the cell, in effect, says,

细胞认为消耗太大，那些细胞就会回应到

"No thanks, I'd actually rather store this energy."

“不了，我更想把这些能量储存起来。”

And because fat cells are actually missing most of

因为脂肪细胞不同于其它细胞

the complex cellular machinery found in other cells,

它没有那么多复杂的结构和组织

it's probably the safest place to store it.

所以能量都被储藏在那。

So for many of us, about 75 million Americans,

因此对我们中许多人，大约7500万美国人来说

the appropriate response to insulin resistance

胰岛素抵抗应被视作

may actually be to store it as fat, not the reverse,

肥胖的成因，而非相反的，

getting insulin resistance in response to getting fat.

将胰岛素抵抗归因于肥胖。

This is a really subtle distinction,

这虽然是个相当微妙的区别，

but the implication could be profound.

但是它的含义却是相当深刻的。

Consider the following analogy:

举个例子来说，

Think of the bruise you get on your shin

想象一下你小腿上的乌青，

when you inadvertently bang your leg into the coffee table.

那是你不小心撞上咖啡桌时留下的。

Sure, the bruise hurts like hell, and you almost certainly

毫无疑问，这乌青疼得要命。

don't like the discolored look, but we all know

而且你肯定不喜欢腿上多个斑，但是我们都知道

the bruise per Se is not the problem.

乌青本身并不是个问题。

In fact, it's the opposite. It's a healthy response to the trauma,

恰恰相反，这是对外伤的一个正常生理反应。

all of those immune cells rushing to the site of the injury

所有的免疫细胞都会迅速前往受伤的部位

to salvage cellular debris and prevent the spread

去清理坏死细胞的碎片并且防止

of infection to elsewhere in the body.

感染扩散到身体其他部位。

Now, imagine we thought bruises were the problem,

好了，想象一下如果我们把乌青当作一个问题，

and we evolved a giant medical establishment

我们发展出了一个庞大的医疗体系

and a culture around treating bruises:

以及文化来对待乌青：

masking creams, painkillers, you name it,

遮蔽霜，止疼药，等等。

all the while ignoring the fact that people

而所有这一切都掩盖了一个事实

are still banging their shins into coffee tables.

那就是人们依旧会撞到咖啡桌

How much better would we be if we treated the cause --

如果我们可以从问题的根源入手

telling people to pay attention

告诉人们注意一下

when they walk through the living room --

从客厅走过的时候小心咖啡桌

rather than the effect?

这会比处理撞伤来的有效果的多

Getting the cause and the effect right

正确理解事情的表象和本因

makes all the difference in the world.

将使这个世界产生巨大的不同。

Getting it wrong, and the pharmaceutical industry

即使治标不治本，制药行业

can still do very well for its shareholders

依旧可以为股东们带来利润，

but nothing improves for the people with bruised shins.

但是对于受伤的人们来说，这没有任何帮助

Cause and effect.

原因及结果。

So what I'm suggesting is

所以我想指出的是

maybe we have the cause and effect wrong

在我们讨论肥胖和胰岛素抵抗的问题时 把原因和结果弄反了。

on obesity and insulin resistance.

在我们讨论肥胖和胰岛素抵抗的问题时 把原因和结果弄反了。

Maybe we should be asking ourselves,

也许我们需要问问我们自己了，

is it possible that insulin resistance causes weight gain

有没有可能胰岛素抵抗导致了体重增加

and the diseases associated with obesity,

以及随肥胖带来的并发症，

at least in most people?

至少对于大多数人来说

What if being obese is just a metabolic response

有没有可能肥胖只是胰岛抵抗的一个代谢反应

to something much more threatening,

相较于其他更大的威胁，

an underlying epidemic,

例如一些相关的疫病，

the one we ought to be worried about?

它们才是我们真正应该去担心的。

Let's look at some suggestive facts.

让我们来看些有暗示性的建议。

We know that 30 million obese Americans

我们知道在美国有3千万肥胖症患者

in the United States don't have insulin resistance.

并未患胰岛素抵抗。

And by the way, they don't appear to be at any

同时，没有证据显示他们

greater risk of disease than lean people.

比非肥胖症患者更容易贻患其他疾病。

Conversely, we know that six million lean people

恰恰相反，在美国有6百万非肥胖症患者

in the United States are insulin-resistant,

存在胰岛素抵抗，

and by the way, they appear to be at even greater risk

而他们却被证实

for those metabolic diseases I mentioned a moment ago

易患那些我之前提到的糖尿病并发症，

than their obese counterparts.

同时几率较肥胖人士来的更高。

Now I don't know why, but it might be because,

虽然现在我还不知道为什么，但是一个可能的原因是，

in their case, their cells haven't actually figured out

对他们而言，他们的细胞无法正确的

the right thing to do with that excess energy.

对体内多余能量做出反应。

So if you can be obese and not have insulin resistance,

你可以是肥胖症患者，却没患胰岛素抵抗，

and you can be lean and have it,

或者你可以不肥胖，却患有胰岛素抵抗，

this suggests that obesity may just be a proxy

这都表明肥胖只不过是一个表征

for what's going on.

而胰岛素抗拒才是根源。

So what if we're fighting the wrong war,

所以如果我们斗争搞错了对象，

fighting obesity rather than insulin resistance?

我们一直与肥胖战斗着，而非胰岛素抵抗？

Even worse, what if blaming the obese

而且更糟的是，如果指责过胖者

means we're blaming the victims?

其实确是在指责胰岛素抵抗的受害者？

What if some of our fundamental ideas about obesity

如果我们对于肥胖症的一些基本认识本身

are just wrong?

就存在误差？

Personally, I can't afford the luxury of arrogance anymore,

就我个人而言，我没有办法继续保持傲慢的态度，

let alone the luxury of certainty.

让我把那种过剩的确信感放在一边。

I have my own ideas about what could be at the heart of this,

对于这些问题的核心为何，我有我自己的认识，

but I'm wide open to others.

同时我也愿意将它与其他人分享

Now, my hypothesis, because everybody always asks me,

我的假设是这样的，因为老有人问我

is this.

我的假设是这样的，因为老有人问我

If you ask yourself, what's a cell trying to protect itself from

试问，一个细胞到底在畏惧什么

when it becomes insulin resistant,

当它处于胰岛素抗拒状态时。

the answer probably isn't too much food.

问题的答案可能不是摄入过多的食物。

It's more likely too much glucose: blood sugar.

答案更有可能是摄入过量葡萄糖而导致血糖过高。

Now, we know that refined grains and starches

精制的谷物和淀粉

elevate your blood sugar in the short run,

将在短时间内抬到你的血糖含量，

and there's even reason to believe that sugar

而且我们有理由相信

may lead to insulin resistance directly.

糖分将直接导致胰岛素抵抗症。

So if you put these physiological processes to work,

所以如果把这些生理过程也列入考虑，

I'd hypothesize that it might be our increased intake

我认为是大量的不断摄入

of refined grains, sugars and starches that's driving

精制谷物，糖类以及淀粉类食物导致了

this epidemic of obesity and diabetes,

肥胖症和糖尿病的流行，

but through insulin resistance,

但其病因是胰岛素抵抗症

you see, and not necessarily through just overeating and under-exercising.

而不是由于暴饮暴食以及缺乏运动。

When I lost my 40 pounds a few years ago,

在我几年前减去40磅时，

I did it simply by restricting those things,

我只是简单的限制了精制谷物，糖，和淀粉的摄入，

which admittedly suggests I have a bias

诚然这也表明我存在一些偏见，

based on my personal experience.

而这些主要源自我的个人经验。

But that doesn't mean my bias is wrong,

但是这并不意味着我的偏见是错误的，

and most important, all of this can be tested scientifically.

更重要的是，所有这些偏见都是可以被科学验证的。

But step one is accepting the possibility

但是第一步就是要接受一种可能性

that our current beliefs about obesity,

那就是我们当前关于肥胖症，

diabetes and insulin resistance could be wrong

糖尿病以及胰岛素抗拒症的理解可能存在偏差

and therefore must be tested.

并需要被验证。

I'm betting my career on this.

我把我的事业都赌在了这个可能性上。

Today, I devote all of my time to working on this problem,

现在，我把所有的时间花在了这个问题的研究上，

and I'll go wherever the science takes me.

而且我将不会停止知道找到真正的答案。

I've decided that what I can't and won't do anymore

我已经决定有一件事是我不能也不会再做的，

is pretend I have the answers when I don't.

那就是在我不知道答案的时候却假装知道。

I've been humbled enough by all I don't know.

对所有我不知道的事情，我都相当谦虚。

For the past year, I've been fortunate enough

在过去一年里，我很幸运

to work on this problem with the most amazing team

可以和国内最优秀的糖尿病和肥胖症专家团队一起研究

of diabetes and obesity researchers in the country,

可以和国内最优秀的糖尿病和肥胖症专家团队一起研究

and the best part is,

同时最好的事情莫过于，

just like Abraham Lincoln surrounded himself with a team of rivals,

就如亚伯拉罕•林肯将自己 置身于由对手组成的团队中

we've done the same thing.

我们也做了一样的事情。

We've recruited a team of scientific rivals,

我们找来了另一个科学家团队作为竞争对手，

the best and brightest who all have different hypotheses

他们也都是极为优秀的科学家，

for what's at the heart of this epidemic.

但却对这个流行病的核心成因有着不同的假设

Some think it's too many calories consumed.

有一些认为是过量的卡路里摄入

Others think it's too much dietary fat.

有一些认为是过量的脂肪摄入

Others think it's too many refined grains and starches.

也有些人为是过量的精制谷物和淀粉摄入。

But this team of multi-disciplinary,

这个由多学科，

highly skeptical and exceedingly talented researchers

具有高度怀疑精神以及相当聪明的研究者团队

do agree on two things.

至少同意两件事情。

First, this problem is just simply too important

其一，这个问题相当重要，

to continue ignoring because we think we know the answer.

以至于我们不能再假装我们知道答案而对它视而不见。

And two, if we're willing to be wrong,

其次，如果我们愿意去犯错误，

if we're willing to challenge the conventional wisdom

如果我们愿意通过科学实践探究去挑战传统观念

with the best experiments science can offer,

如果我们愿意通过科学实践探究去挑战传统观念

we can solve this problem.

我们终将解决这个问题。

I know it's tempting to want an answer right now,

我知道我们都希望现在就能得到一个答案，

some form of action or policy, some dietary prescription --

一些可以参照行为方式或者规则，一些饮食菜单

eat this, not that —

告诉我们该吃什么，不该吃什么，

but if we want to get it right,

但是如果我们想找到一个正确的答案，

we're going to have to do much more rigorous science

我们就不得不进行严谨的科学尝试，

before we can write that prescription.

不然我们是给出真正的答案的。

Briefly, to address this, our research program

简而言之，为了找到这个答案，我们的研究项目

is focused around three meta-themes, or questions.

主要围绕着三个方面或者问题展开。

First, how do the various foods we consume

首先，我们摄入的各种各样的食物是如何

impact our metabolism, hormones and enzymes,

影响我们的代谢，激素和酶的，

and through what nuanced molecular mechanisms?

并且这些影响是通过何种细微的分子机制发生的？

Second, based on these insights,

其二，基于这个视角，

can people make the necessary changes in their diets

人们有没有办法对他们的饮食做出必要的调整，

in a way that's safe and practical to implement?

使它更安全且更易实践

And finally, once we identify what safe

最终，一旦我们找到既安全、

and practical changes people can make to their diet,

又能安全应用到饮食中的方法

how can we move their behavior in that direction

我们又如何改变他们的习惯，

so that it becomes more the default

使之变得更为自然，

rather than the exception?

而非一种刻意行为？

Just because you know what to do doesn't mean

你知道应该去做什么并不意味着

you're always going to do it.

你可以坚持这么做。

Sometimes we have to put cues around people

有时我们不得不给人们一些诱因

to make it easier, and believe it or not,

使这种坚持变得更简单，不管你信不信

that can be studied scientifically.

这都可以经过科学研究

I don't know how this journey is going to end,

我不知道这个研究最终会将我带向何处，

but this much seems clear to me, at least:

但是对我而言，至少有一点是可以肯定地：

We can't keep blaming our overweight and diabetic patients

我们不能继续指责肥胖症和糖尿病患者

like I did.

就像曾经的我那样。

Most of them actually want to do the right thing,

他们中的大部分其实都想做正确的选择，

but they have to know what that is,

但前提是他们必须知道到底什么是正确的，

and it's got to work.

而且它们切实可行。

I dream of a day when our patients can

我们梦想有一天当我们的患者可以

shed their excess pounds

减去多余的重量

and cure themselves of insulin resistance,

治好胰岛素抵抗症，

because as medical professionals,

因为作为医学专家，

we've shed our excess mental baggage

我们已经抛开了多余的思想包袱，

and cured ourselves of new idea resistance sufficiently

并完全治好了自己的新观点抵抗症

to go back to our original ideals:

从而使我们回归我们最初的理想：

open minds, the courage to throw out yesterday's ideas

开放的思维，抛弃那些不再有效的陈旧观念的勇气

when they don't appear to be working,

开放的思维，抛弃那些不再有效的陈旧观念的勇气

and the understanding that scientific truth isn't final,

相信科学的真理没有终点，

but constantly evolving.

只有不断的进化。

Staying true to that path will be better for our patients

忠于这条追求真理的道路 对患者和科学来说都是更好的选择

and better for science.

忠于这条追求真理的道路 对患者和科学来说都是更好的选择

If obesity is nothing more than a proxy

如果肥胖只是

for metabolic illness,

代谢疾病的一个替罪羊，

what good does it do us to punish those with the proxy?

那么我们去指责这些替罪羊又有什么好处呢？

Sometimes I think back to that night in the E.R.

我有时会回想到七年前急救室的那个夜晚

seven years ago.

我有时会回想到七年前急救室的那个夜晚

I wish I could speak with that woman again.

我希望我可以再和那位女士聊聊。

I'd like to tell her how sorry I am.

我想向她道歉。

I'd say, as a doctor, I delivered

我想说，作为一个医生，我提供了

the best clinical care I could,

我所能提供的最好的治疗，

but as a human being,

但是最为一个人，

I let you down.

我让你失望了。

You didn't need my judgment and my contempt.

你需要的不是我的判定和我的鄙视。

You needed my empathy and compassion,

你需要的是我的同情和怜悯，

and above all else, you needed a doctor

而且无论如何，你需要的是一个医生

who was willing to consider

愿意相信

maybe you didn't let the system down.

也许你没有辜负我们的医疗系统。

Maybe the system, of which I was a part,

也许是医疗系统，包括我在内的这个医疗系统，

was letting you down.

辜负了你。

If you're watching this now,

如果你现在正在看这个演讲，

I hope you can forgive me.

我希望你可以原谅我。

(Applause)

（掌声）