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

Translator: Joseph Geni Reviewer: Morton Bast

Translator: Wu Benise Reviewer: Bighead Ge

I'll never forget that day

2006 年嘅春天

back in the spring of 2006.

發生咗一件無辦法忘記嘅事

I was a surgical resident

我當時係約翰斯 · 霍普金斯醫院 外科駐院醫生

at The Johns Hopkins Hospital,

taking emergency call.

負責急症

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

有朝凌晨兩點

急症室打嚟，叫我返去醫院

to come and see a woman with a diabetic ulcer

睇一個隻腳患咗糖尿病潰瘍嘅女病人

on her foot.

I can still remember sort of that smell of rotting flesh

我到而家都仲記得拉開塊簾

as I pulled the curtain back to see her.

聞到一陣潰爛味

And everybody there agreed this woman was very sick

所有人都認為呢位女士 病情嚴重，需要留醫

and she needed to be in the hospital.

That wasn't being asked.

咁呢當然啦仲使問

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

但我當時仲有一個疑問

which was, did she also need an amputation?

佢駛唔駛做切肢手術？

Now, looking back on that night,

而家，諗返嗰晚嘅事

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

我拼命令自己相信

我對待呢一位女病人嘅心

on that night with the same empathy and compassion

同對另一位女病人嘅心，都係一樣

I'd shown the 27-year-old newlywed

第二位病人 27 歲、結婚冇耐

就喺第一位病人入嚟急症室前嘅三日

who came to the E.R. three nights earlier

with lower back pain

因為下腰痛嚟到急症室

that turned out to be advanced pancreatic cancer.

結果驗出比較後期嘅胰腺癌

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

我知道我做唔到咩保住佢嘅性命

that was actually going to save her life.

The cancer was too advanced.

癌症已經好後期

But I was committed to making sure that

但我仍然向佢保證

I could do anything possible to make her stay

我會盡一切努力令佢更加舒服

more comfortable. I brought her a warm blanket

我帶咗佢一張毯同一杯咖啡

and a cup of a coffee.

I brought some for her parents.

我亦都帶咗啲畀佢父母

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

但更重要嘅係，我冇批評過佢

because obviously she had done nothing

因為好明顯，佢患呢個病係無辜嘅

to bring this on herself.

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

咁點解，幾晚之後，我喺同一間急症室

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

決定我嘅糖尿病人需要截肢？

that my diabetic patient did indeed need an amputation,

why did I hold her in such bitter contempt?

點解我會咁樣睇低佢呢？

You see, unlike the woman the night before,

同第二位女病人唔同

this woman had type 2 diabetes.

第一位病人有第二類糖尿病，而且肥胖

She was fat.

And we all know that's from eating too much

我哋都知道第二類糖尿病

and not exercising enough, right?

係因為食太多 同唔夠運動引起，係咪？

I mean, how hard can it be?

我嘅意思係 食少啲同做運動有幾難呢？

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

我望住佢瞓喺床，心諗

if you just tried caring even a little bit,

如果你以前關心自己多啲

you wouldn't be in this situation at this moment

你而家就唔會俾醫生截肢

with some doctor you've never met

about to amputate your foot.

Why did I feel justified in judging her?

點解我會覺得咁樣評價佢係合理呢？

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

我想答我唔知道

But I actually do.

但我其實心裏面係有原因

You see, in the hubris of my youth,

你睇下，年輕嘅我幾咁傲慢

I thought I had her all figured out.

覺得自己好了解病人

She ate too much. She got unlucky.

認為病人因為食得太多，同埋唔好彩

She got diabetes. Case closed.

所以患上糖尿病。完

Ironically, at that time in my life,

諷刺嘅係我當時做緊癌症研究

I was also doing cancer research,

immune-based therapies for melanoma, to be specific,

研究以免疫系統為本嘅黑色素瘤療法

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

研究裏面，我學到要凡事問問題

to challenge all assumptions

質疑所有假設

and hold them to the highest possible scientific standards.

同埋將研究保持喺最高嘅科學標準

Yet when it came to a disease like diabetes

但講到一啲好似糖尿病咁嘅病

that kills Americans eight times more frequently than melanoma,

比黑色素瘤奪去多八倍美國人嘅病

I never once questioned the conventional wisdom.

我從未懷疑過前人知識

I actually just assumed the pathologic sequence of events

我假設咗以前讀到嘅 病理發展次序係成形嘅科學

was settled science.

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

三年後，我終於明白自己有幾錯

But this time, I was the patient.

但今次，我係一個病人

Despite exercising three or four hours every single day,

雖然我每日都會做三至四個鐘運動

and following the food pyramid to the letter,

並且不折不扣跟足食物金字塔

I'd gained a lot of weight and developed something

我嘅體重仍然增加

called metabolic syndrome.

而且患上咗代謝症候群

Some of you may have heard of this.

可能在座有人會聽過呢個病

I had become insulin-resistant.

我個身體突然抗拒胰島素

You can think of insulin as this master hormone

各位可以想像胰島素係一種主要激素

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

控制身體對食咗嘅食物作出反應

whether we burn it or store it.

話畀身體知消耗定儲存食物

This is called fuel partitioning in the lingo.

呢個生理反應叫能量分區

Now failure to produce enough insulin is incompatible with life.

產生唔到足夠胰島素係難以令人生活

And insulin resistance, as its name suggests,

而抗胰島素，顧名思義

is when your cells get increasingly resistant

就係細胞對胰島素所做嘅嘢愈嚟愈抗拒

to the effect of insulin trying to do its job.

Once you're insulin-resistant,

當你係抗胰島素，糖尿病就會埋你身

you're on your way to getting diabetes,

which is what happens when your pancreas

你嘅胰腺就會因為抗胰島素嘅關係

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

製造唔到足夠嘅胰島素

Now your blood sugar levels start to rise,

血糖於是會上升

and an entire cascade of pathologic events

然後病情就會失控

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

最終引致心臟病、癌症 阿爾茨海默氏病，同埋截肢

cancer, even Alzheimer's disease,

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

即係好似幾年前嗰位女士咁樣

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

因為我好驚會變成咁

所以我徹底改變咗飲食習慣

adding and subtracting things most of you would find

飲食上開始食加同減一啲 大部分人會驚訝嘅嘢

almost assuredly shocking.

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

做咗之後令我輕咗 40 磅

奇怪嘅係我做少咗運動

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

大家見到，我已經唔再超重

More importantly, I don't have insulin resistance.

更重要嘅係，抗胰島素無再發生

But most important, I was left

但最重要嘅係

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

我仲有三個急需解決嘅問題︰

How did this happen to me if I was supposedly

假如我嘅生活習慣係健康

doing everything right?

咁點解呢個病係會發生喺我身上呢？

If the conventional wisdom about nutrition had failed me,

如果有關營養嘅舊有知識 對我唔適用嘅話

was it possible it was failing someone else?

會唔會對其他人都係咁？

And underlying these questions,

問咗呢啲問題之後

I became almost maniacally obsessed

我更加想了解 肥胖同抗胰島素之間嘅真正關係

in trying to understand the real relationship

between obesity and insulin resistance.

Now, most researchers believe obesity

如今，大部分學者都相信

is the cause of insulin resistance.

肥胖係抗胰島素嘅原因

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

咁照邏輯推理，如果想醫好抗胰島素

you get people to lose weight, right?

我哋就要鼓勵啲人減肥，係咪？

You treat the obesity.

所以我哋要醫肥胖

But what if we have it backwards?

但係如果個關係調轉呢？

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

如果肥胖根本唔係抗胰島素嘅原因？

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

如果肥胖反映緊一個更深嘅問題？

the tip of a proverbial iceberg?

我知咁講好似好癲

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

因為我哋都經歷梗肥胖流行病嘅爆發

of an obesity epidemic, but hear me out.

但請先聽我講

What if obesity is a coping mechanism

如果肥胖係一個機制

for a far more sinister problem going on

畀我哋抵禦更加兇險嘅細胞問題？

underneath the cell?

I'm not suggesting that obesity is benign,

我唔係講緊肥胖係好事

but what I am suggesting is it may be the lesser

但我認為肥胖係兩種代謝問題之中

of two metabolic evils.

影響比較輕微嗰個

You can think of insulin resistance as the reduced capacity

你可以將抗胰島素諗成 細胞獲取能量嘅能力下降

of our cells to partition fuel,

as I alluded to a moment ago,

就好似我頭先提到

taking those calories that we take in

當我哋攝取卡路里嘅時候

and burning some appropriately and storing some appropriately.

我哋會將部分消耗同部分儲存

When we become insulin-resistant,

當我哋患上抗胰島素時

the homeostasis in that balance deviates from this state.

消耗同儲存嘅平衡就會消失

So now, when insulin says to a cell,

宜家當胰島素同細胞講

I want you to burn more energy

「我要你消耗更多能量」

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

但因為細胞覺得消耗率大過安全水平

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

所以會話「唔駛啦，我會蓄能量」

And because fat cells are actually missing most of

而由於脂肪細胞欠缺 其他細胞大部分複雜嘅細胞機制

the complex cellular machinery found in other cells,

it's probably the safest place to store it.

所以佢哋係一個安全嘅地方儲存能量

So for many of us, about 75 million Americans,

所以對於我哋好多美國人嚟講

即係七千五百萬人嚟講

the appropriate response to insulin resistance

對抗胰島素最合適嘅做法 反而係我哋儲存脂肪

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

getting insulin resistance in response to getting fat.

而唔係因為肥胖所以有抗胰島素

This is a really subtle distinction,

呢兩個次序雖然分別唔大，但意義深遠

but the implication could be profound.

Consider the following analogy:

大家嘗試諗下以下比喻：

Think of the bruise you get on your shin

當你唔小心俾茶几撞到隻腳時

when you inadvertently bang your leg into the coffee table.

皮膚會有瘀傷

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

當然，瘀傷係好痛

你亦都唔會鍾意變咗色嘅皮膚

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

但我哋知道瘀傷唔係問題

the bruise per Se is not the problem.

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

相反，佢係對創傷嘅一個健康反應

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

所有免疫細胞趕去受傷嘅地方

to salvage cellular debris and prevent the spread

阻止細胞殘骸擴散

同埋防止身體其他部位受到感染

of infection to elsewhere in the body.

Now, imagine we thought bruises were the problem,

而家，假設我哋覺得瘀傷係一個問題

and we evolved a giant medical establishment

而且研發到一種醫學技術

and a culture around treating bruises:

同埋形成一種文化去治療瘀傷

masking creams, painkillers, you name it,

當中包括有掩蔽霜、止痛藥 各種你哋諗到嘅嘢都有

all the while ignoring the fact that people

但係我哋忽略咗 人仍然會撞到茶几呢個事實

are still banging their shins into coffee tables.

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

如果我哋根治呢個原因

叫人喺客廳行嘅時候小心啲

telling people to pay attention

when they walk through the living room --

而唔係對付個後果

rather than the effect?

你話係咪好得多呢？

Getting the cause and the effect right

搞清原因同後果，世界從此會好唔同

makes all the difference in the world.

Getting it wrong, and the pharmaceutical industry

攪錯咗嘅話

醫藥行業可以仍然會發展得好好

can still do very well for its shareholders

but nothing improves for the people with bruised shins.

但人嘅小腿嘅瘀傷點都唔會有改善

Cause and effect.

講到因果關係

So what I'm suggesting is

所以我要講嘅係

maybe we have the cause and effect wrong

可能我哋攪錯咗 肥胖同抗胰島素嘅因果關係

on obesity and insulin resistance.

Maybe we should be asking ourselves,

我哋可能要問問自己

is it possible that insulin resistance causes weight gain

喺至少大部分人當中

抗胰島素有冇可能導致肥胖 同各種同肥胖相關嘅疾病呢？

and the diseases associated with obesity,

at least in most people?

What if being obese is just a metabolic response

肥胖會唔會只係一樣 對更有威脅嘅嘢嘅反應呢？

to something much more threatening,

an underlying epidemic,

例如隱性病

咁我哋需唔需要擔心呢？

the one we ought to be worried about?

Let's look at some suggestive facts.

我哋睇下一啲事實

We know that 30 million obese Americans

有三千萬肥胖嘅美國人係無抗胰島素

in the United States don't have insulin resistance.

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

佢哋唔會比瘦嘅人有更大嘅疾病風險

greater risk of disease than lean people.

Conversely, we know that six million lean people

相反，美國有六百萬瘦嘅人有抗胰島素

in the United States are insulin-resistant,

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

佢哋比肥胖嘅人更加易患上 剛才提及嘅代謝性疾病嘅風險

for those metabolic diseases I mentioned a moment ago

than their obese counterparts.

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

我唔知原因，但有可能因為

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

佢哋嘅細胞唔知點樣應對多咗嘅能量

the right thing to do with that excess energy.

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

所以，當人可以肥胖而無患上抗胰島素

and you can be lean and have it,

而你瘦嘅人都可以患上抗胰島素嘅話

this suggests that obesity may just be a proxy

肥胖可以推斷只係一個身體狀態嘅訊號

for what's going on.

So what if we're fighting the wrong war,

如果我哋醫錯咗

剩係醫肥胖而唔係醫抗胰島素

fighting obesity rather than insulin resistance?

咁會有咩後果？

Even worse, what if blaming the obese

更差嘅係，如果肥胖嘅人 其實係受害者嘅話

means we're blaming the victims?

咁點算呢？

What if some of our fundamental ideas about obesity

如果我哋對肥胖嘅認識根本係錯架呢？

are just wrong?

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

個人嚟講，我承受唔起自大嘅後果

let alone the luxury of certainty.

更受唔起做事絕對嘅後果

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

我對呢件事有我自己一套睇法 但我亦都樂意聽其他人意見

but I'm wide open to others.

Now, my hypothesis, because everybody always asks me,

由於每個人都問我 所以我會講講我嘅假定

is this.

如果你問我

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

當一個細胞抵抗胰島素嘅時候 究竟佢係遠離緊啲咩

when it becomes insulin resistant,

the answer probably isn't too much food.

答案應該唔係過多嘅食物

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

而係過多嘅葡萄糖 ，亦即係血糖

Now, we know that refined grains and starches

我哋知道加工嘅穀物同澱粉 會短時間內增加血糖

elevate your blood sugar in the short run,

and there's even reason to believe that sugar

而且有理由相信

may lead to insulin resistance directly.

糖份可能會直接導致抗胰島素

So if you put these physiological processes to work,

所以，如果思考整個生理過程

I'd hypothesize that it might be our increased intake

我會假設增加攝取 加工穀物、糖份同埋澱粉

of refined grains, sugars and starches that's driving

this epidemic of obesity and diabetes,

會透過抗胰島素嘅現象 導致肥胖同埋糖尿病

but through insulin resistance,

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

而唔一定剩關食過多同太少運動

When I lost my 40 pounds a few years ago,

幾年前，我只係控制食量同運動量

I did it simply by restricting those things,

我就輕咗 40 磅

which admittedly suggests I have a bias

我承認呢一個係偏見嚟

based on my personal experience.

因為係我嘅個人經歷

But that doesn't mean my bias is wrong,

但咁樣唔代表我嘅偏見係錯

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

最重要係，全部嘢都可經得起科學驗證

But step one is accepting the possibility

不過首要接受

that our current beliefs about obesity,

我哋現有對肥胖、糖尿病 同埋抗胰島素嘅觀念可能係錯

diabetes and insulin resistance could be wrong

and therefore must be tested.

所以呢啲觀念都要驗證埋

I'm betting my career on this.

我亦為呢樣嘢賭上我嘅生涯

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

今日，我用我所有時間去研究呢個問題

and I'll go wherever the science takes me.

我會跟著科學嘅指引去做

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

當我決定無辦法或者唔去做一件事

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

其實係假扮知道答案

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

我對於唔知嘅嘢一直好謙虛

For the past year, I've been fortunate enough

過去嘅一年裡面，我好幸運

to work on this problem with the most amazing team

能夠同國內最優秀嘅 研究糖尿病同肥胖嘅團隊

of diabetes and obesity researchers in the country,

共同探索呢一個問題

and the best part is,

最美好嘅部分係我哋好似林肯咁

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

被同時係競爭對手嘅隊員包圍

we've done the same thing.

We've recruited a team of scientific rivals,

我哋其實請嚟一班最頂尖最優秀

the best and brightest who all have different hypotheses

又對呢一個病各有見解嘅科學團隊

for what's at the heart of this epidemic.

Some think it's too many calories consumed.

其中有啲認為原因係攝取過多卡路里

Others think it's too much dietary fat.

有啲認為係飲食高脂

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

有啲認為係進食太多加工嘅穀物和澱粉

But this team of multi-disciplinary,

呢個團隊雖然嚟自多個範疇

highly skeptical and exceedingly talented researchers

又有好高批判能力同又係好叻

do agree on two things.

但佢哋同意兩樣嘢

First, this problem is just simply too important

第一，因為我哋以為知道答案

to continue ignoring because we think we know the answer.

所以可以繼續忽視呢個重要問題

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

第二，如果我哋願意接受自己係錯

if we're willing to challenge the conventional wisdom

並且願意利用最好嘅科學實驗 去挑戰舊有概念

with the best experiments science can offer,

we can solve this problem.

我哋就可以解決問題

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

我哋都好想即刻有一個答案

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

雖然宜家有各種形式嘅行動同政策

同埋一啲飲食配方

eat this, not that —

例如食呢樣，唔好食嗰樣

but if we want to get it right,

但如果我哋真係想對症下藥

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

我哋喺處方之前 我哋需要更嚴格嘅科學校證

before we can write that prescription.

Briefly, to address this, our research program

簡單嚟講，我哋嘅研究計劃

is focused around three meta-themes, or questions.

針對三個大主題或者問題

First, how do the various foods we consume

第一，我哋食嘅各種食物點樣 透過精密嘅的分子機制

impact our metabolism, hormones and enzymes,

and through what nuanced molecular mechanisms?

影響新陳代謝、激素同埋酶呢？

Second, based on these insights,

第二，根據以上答案

can people make the necessary changes in their diets

人可唔可以對飲食習慣 作出安全而又實際嘅改變呢？

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

And finally, once we identify what safe

最後，當我哋搵到安全又實際嘅 飲食習慣畀人去跟嘅時候

and practical changes people can make to their diet,

how can we move their behavior in that direction

我哋點樣普及呢一批人嘅行為

so that it becomes more the default

而唔係畀人覺得係另類嘅一群呢？

rather than the exception?

Just because you know what to do doesn't mean

我哋知道應該去做咩嘢 唔代表我哋會做

you're always going to do it.

Sometimes we have to put cues around people

有時候，我哋需要引導人

to make it easier, and believe it or not,

令研究更加科學化地進行

that can be studied scientifically.

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

我唔知呢一個旅程嘅終點係點

but this much seems clear to me, at least:

但最少有一件事係好清楚

We can't keep blaming our overweight and diabetic patients

就係我哋唔可以好似我以前咁

鬧嗰啲過重同埋患上糖尿病嘅人

like I did.

Most of them actually want to do the right thing,

佢哋大部分人都想糾正自己

but they have to know what that is,

但佢哋需要知道方向點樣行 同埋方向係要可行

and it's got to work.

I dream of a day when our patients can

我夢想有一日我哋嘅病人 能夠卸下過重嘅罪名

shed their excess pounds

and cure themselves of insulin resistance,

同埋醫好佢哋嘅抗胰島素

because as medical professionals,

因為作為醫學專家

we've shed our excess mental baggage

我哋已經卸下心理包袱

and cured ourselves of new idea resistance sufficiently

同埋醫好咗抗拒新見解嘅毛病

to go back to our original ideals:

我哋返返去我哋原本嘅理想：

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

開放諗法

當昨日嘅觀念唔再啱用 就要有勇氣捨棄昨日嘅觀念

when they don't appear to be working,

and the understanding that scientific truth isn't final,

同埋要明白科學無永遠嘅事實 而係不斷演變緊嘅

but constantly evolving.

Staying true to that path will be better for our patients

緊守呢個諗法對我哋病人 同埋科學都有好處

and better for science.

If obesity is nothing more than a proxy

如果肥胖只係代謝性疾病嘅徵兆

for metabolic illness,

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

懲罰呢啲有徵兆嘅人 對我哋有咩好處呢？

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

有時我會諗返起七年前 喺急症室嗰一晚

seven years ago.

I wish I could speak with that woman again.

我好想再同嗰一位女士傾偈

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

我想同佢講我有幾咁內疚

I'd say, as a doctor, I delivered

我會講，作為一個醫生

the best clinical care I could,

我提供咗最好嘅臨床護理

but as a human being,

但作為一個普通人

I let you down.

我令到你失望

You didn't need my judgment and my contempt.

你唔需要我嘅批評同埋蔑視

You needed my empathy and compassion,

你需要嘅係我嘅同情同憐憫

and above all else, you needed a doctor

除此之外，你仲需要一個醫生

who was willing to consider

佢願意考慮︰

maybe you didn't let the system down.

未必係你令社會失望

Maybe the system, of which I was a part,

而係個社會，包括我在內，令你失望

was letting you down.

If you're watching this now,

如果你而家睇緊呢一個講座

I hope you can forgive me.

希望你會原諒我

(Applause)

（掌聲）