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

Translator: Joseph Geni Reviewer: Morton Bast

譯者: Patty Chuang 審譯者: Yi-Ting Chung

I'll never forget that day

我永遠不會忘記那天

back in the spring of 2006.

在 2006 年春天的時候

I was a surgical resident

我當時是一位外科住院醫師

at The Johns Hopkins Hospital,

在約翰·霍普金斯醫院工作

taking emergency call.

接緊急任務

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

大約凌晨兩點時急診室叫我過去

to come and see a woman with a diabetic ulcer

幫一名糖尿病足部潰瘍的女士看診

on her foot.

I can still remember sort of that smell of rotting flesh

我還記得當我拉開隔簾看她時

as I pulled the curtain back to see her.

那種肉體腐爛的味道

And everybody there agreed this woman was very sick

在場的人一致認為她病得很嚴重

and she needed to be in the hospital.

必須住院治療

That wasn't being asked.

這大家所認同的

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

但他們問我的是另一個問題

which was, did she also need an amputation?

也就是，她需要截肢嗎

Now, looking back on that night,

而當我回想起那一晚

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

我極度地希望當時

我對那位女士的治療態度， 賦予著的同情和憐憫

on that night with the same empathy and compassion

I'd shown the 27-year-old newlywed

不亞於另一位 27 歲的新婚女士

who came to the E.R. three nights earlier

她當晚三天前來到急診室

with lower back pain

說她的下背部疼痛

that turned out to be advanced pancreatic cancer.

後來診斷出是胰腺癌末期

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

她的情況我知道 我無法給她任何醫療幫助

that was actually going to save her life.

來挽救她的生命

The cancer was too advanced.

那癌症已經末期了

But I was committed to making sure that

但我有責任確保

I could do anything possible to make her stay

盡量讓她維持在舒適的狀態

more comfortable. I brought her a warm blanket

我幫她多加一件被子

and a cup of a coffee.

給她一杯咖啡

I brought some for her parents.

也幫她父母親買咖啡

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

但最重要的是，我不怪她

because obviously she had done nothing

因為顯然她並沒有做錯什麼事

to bring this on herself.

害她變成這樣

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

但為什麼，幾天之後

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

我站在同一間急診室

that my diabetic patient did indeed need an amputation,

決定這位糖尿病患者需要截肢時

why did I hold her in such bitter contempt?

對她卻持有輕蔑的態度？

You see, unlike the woman the night before,

大家可以發現，和前三天那位女士不同

this woman had type 2 diabetes.

這位女士有二型糖尿病

She was fat.

她有肥胖的問題

And we all know that's from eating too much

我們都知道這是因為吃太多

and not exercising enough, right?

而且運動量不足，沒錯吧

I mean, how hard can it be?

我的意思是這會有多難呢？

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

低頭看著她躺在床上，我心想

if you just tried caring even a little bit,

如果妳能多留意一點

you wouldn't be in this situation at this moment

現在就不會處於這種情況

with some doctor you've never met

一堆妳沒見過的醫生

about to amputate your foot.

即將要幫妳截肢

Why did I feel justified in judging her?

為什麼這樣批評她是合理的

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

我想說我不知道

But I actually do.

但其實我明白

You see, in the hubris of my youth,

當時年少輕狂

I thought I had her all figured out.

我以為我看透她這種人

She ate too much. She got unlucky.

她吃太多，她運氣不好

She got diabetes. Case closed.

得了糖尿病，就這樣

Ironically, at that time in my life,

諷刺的是當時

I was also doing cancer research,

我在研究癌症

immune-based therapies for melanoma, to be specific,

具體一點是黑色素瘤的免疫治療

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

在這個領域當中我被教導去質疑一切

to challenge all assumptions

要挑戰所有假設

and hold them to the highest possible scientific standards.

然後盡可能用最高的科學標準來衡量

Yet when it came to a disease like diabetes

然而講到糖尿病這類疾病

that kills Americans eight times more frequently than melanoma,

在美國，致命率比黑色素瘤高八倍

I never once questioned the conventional wisdom.

我從來不質疑傳統的觀念

I actually just assumed the pathologic sequence of events

我其實已經假設病理學中的先後順序

was settled science.

已由科學證實

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

三年後，我發現我大錯特錯

But this time, I was the patient.

但這一次我成了病人

Despite exercising three or four hours every single day,

儘管我每天運動３~４小時

and following the food pyramid to the letter,

飲食也遵循食物金字塔的概念

I'd gained a lot of weight and developed something

仍然體重暴增

called metabolic syndrome.

得了新陳代謝症候群

Some of you may have heard of this.

在座可能有些人有聽過

I had become insulin-resistant.

我身體有了胰島素抗性

You can think of insulin as this master hormone

你們可以把胰島素想成一種主激素

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

它在我們進食後掌控身體相關的運作

whether we burn it or store it.

燃燒能量或儲存能量

This is called fuel partitioning in the lingo.

行話我們叫做燃料分區

Now failure to produce enough insulin is incompatible with life.

無法分泌足夠的胰島素有生命危險

And insulin resistance, as its name suggests,

胰島素抗性，顧名思義

is when your cells get increasingly resistant

就是細胞開始

to the effect of insulin trying to do its job.

急劇抗拒胰島素發揮它的功能

Once you're insulin-resistant,

一旦身體有了胰島素抗性

you're on your way to getting diabetes,

就會得糖尿病

which is what happens when your pancreas

糖尿病就是你的胰腺

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

無法產生足夠的胰島素 來跟上抗性的程度

Now your blood sugar levels start to rise,

血糖開始升高

and an entire cascade of pathologic events

然後一連串的病理事件

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

開始失去控制因而導致心臟病

cancer, even Alzheimer's disease,

癌症，甚至阿茲海默症

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

或者像前幾年那位女士一樣截肢

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

我受到驚嚇並開始徹底改善飲食習慣

adding and subtracting things most of you would find

加加減減一些

almost assuredly shocking.

你們大部分會滿意外的食物

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

我瘦了 40 磅但奇怪的是我運動量有所減少

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

你們猜也知道，顯然我不再過重

More importantly, I don't have insulin resistance.

更重要的是我的身體沒有胰島素抗性了

But most important, I was left

但最重要的是

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

在這之後我有三個急迫的問題揮之不去

How did this happen to me if I was supposedly

為什麼這種事會發生在我身上

明明我做的應該都是對的事

doing everything right?

If the conventional wisdom about nutrition had failed me,

如果對營養的傳統觀念不適用在我身上

was it possible it was failing someone else?

是不是可能對別人也不適用呢

And underlying these questions,

因為這些問題

I became almost maniacally obsessed

我幾乎開始瘋狂著迷

in trying to understand the real relationship

試著找出肥胖與胰島素抗性之間

between obesity and insulin resistance.

真正的關聯

Now, most researchers believe obesity

現在大部分的研究人員相信

is the cause of insulin resistance.

是肥胖導致身體產生胰島素抗性

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

所以邏輯上來講，要治療胰島素抗性

you get people to lose weight, right?

就是減重對吧

You treat the obesity.

就是治療肥胖的問題

But what if we have it backwards?

但如果正好相反呢

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

萬一根本不是肥胖導致胰島素抗性呢

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

萬一其實是一個更嚴重的症狀

the tip of a proverbial iceberg?

而它只是眾所皆知的冰山一角而已呢

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

我知道這聽起來有點瘋狂，因為我們明顯地

of an obesity epidemic, but hear me out.

還在這肥胖問題的流行病之中，但讓我解釋一下

What if obesity is a coping mechanism

會不會其實肥胖是一種應對機制

for a far more sinister problem going on

為了來面對潛藏於細胞中

underneath the cell?

更嚴重的問題呢

I'm not suggesting that obesity is benign,

我不是說肥胖是好事

but what I am suggesting is it may be the lesser

我想表達的是，兩個新陳代謝惡魔相較下

of two metabolic evils.

肥胖是次要的

You can think of insulin resistance as the reduced capacity

你可以把胰島素抗性想成

of our cells to partition fuel,

我們身體為燃料分區的能力下降了

as I alluded to a moment ago,

像我剛剛提到的

taking those calories that we take in

身體將我們攝取的卡路里

and burning some appropriately and storing some appropriately.

適當的燃燒及儲存

When we become insulin-resistant,

當我們身體出現胰島素抗性時

the homeostasis in that balance deviates from this state.

體內的狀態失去平衡

So now, when insulin says to a cell,

所以現在，當胰島素跟細胞說

I want you to burn more energy

我要你燃燒更多能量

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

超過細胞視為安全的程度

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

細胞會說謝了我要把能量存起來

And because fat cells are actually missing most of

但脂肪細胞缺少

the complex cellular machinery found in other cells,

其他細胞中大部分複雜的機制結構

it's probably the safest place to store it.

它可能成了儲存能量最安全的地方

So for many of us, about 75 million Americans,

所以約7500萬美國人，我們大多

the appropriate response to insulin resistance

對胰島素抗性的正常反應

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

事實上都是存成脂肪細胞，而非相反的

getting insulin resistance in response to getting fat.

因為肥胖而產生胰島素抗性

This is a really subtle distinction,

其實兩者差別不大

but the implication could be profound.

但其隱含的意義深遠

Consider the following analogy:

想一想接下來這個的類比

Think of the bruise you get on your shin

你的腳瘀青了

when you inadvertently bang your leg into the coffee table.

因為不小心撞到咖啡桌

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

當然瘀青讓你痛得要命，你也絕對

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

不喜歡瘀青的顏色，但我們都知道

the bruise per Se is not the problem.

瘀青本身不是問題

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

事實上相反的，它對傷口是一個好的反應

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

這些免疫細胞衝到受傷部位

to salvage cellular debris and prevent the spread

為了拯救破損細胞，而避免細胞感染

of infection to elsewhere in the body.

擴散到身體其他部位

Now, imagine we thought bruises were the problem,

現在假如我們把瘀青當作問題所在

and we evolved a giant medical establishment

我們發展出巨大的醫療機構及文化

and a culture around treating bruises:

專門在研究如何治療瘀青

masking creams, painkillers, you name it,

遮瑕乳液、止痛藥和任何你講得出來的東西

all the while ignoring the fact that people

而我們這段時間都忽略了一個事實

are still banging their shins into coffee tables.

人的膝蓋還是會撞到咖啡桌

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

對症下藥會不會更好

telling people to pay attention

告訴大家要小心

when they walk through the living room --

進出客廳要注意咖啡桌

rather than the effect?

而不是針對傷害做治療

Getting the cause and the effect right

如果我們瞭解因果關係

makes all the difference in the world.

會讓世界變得不同

Getting it wrong, and the pharmaceutical industry

弄錯前因後果

藥物產業的股東沒有損失

can still do very well for its shareholders

but nothing improves for the people with bruised shins.

但對瘀青的人沒有任何幫助

Cause and effect.

這是因果關係的問題

So what I'm suggesting is

所以我想表達的是

maybe we have the cause and effect wrong

或許我們搞錯了

on obesity and insulin resistance.

肥胖和胰島素抗性的因果關係

Maybe we should be asking ourselves,

我們也許該問問自己

is it possible that insulin resistance causes weight gain

會不會是因為胰島素抗性而造成體重增加

and the diseases associated with obesity,

還有其它與肥胖有關的疾病

at least in most people?

至少大部分的人是如此

What if being obese is just a metabolic response

會不會肥胖只是一個新陳代謝的反應

to something much more threatening,

用來對付更具威脅性的

an underlying epidemic,

潛在流行病

the one we ought to be worried about?

而這流行病才是我們該擔心的問題

Let's look at some suggestive facts.

我們來看看一些相關的案例

We know that 30 million obese Americans

我們知道美國有3000萬肥胖的人

in the United States don't have insulin resistance.

並沒有胰島素抗性的症狀

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

順便一提，他們罹患疾病的風險

greater risk of disease than lean people.

不會比瘦的人還高

Conversely, we know that six million lean people

相反的，我們知道美國有600萬瘦的人

in the United States are insulin-resistant,

有胰島素抗性

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

順便跟你們說，他們有更高的風險

for those metabolic diseases I mentioned a moment ago

會得到我剛剛提到的那些代謝疾病

than their obese counterparts.

而且比那些相對肥胖的人機率更高

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

我不懂為什麼，但有可能他們的情況

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

是因為細胞沒有辦法理解

the right thing to do with that excess energy.

多餘的能量該如何使用

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

所以如果肥胖的人沒有胰島素抗性

and you can be lean and have it,

或者瘦的人卻有胰島素抗性

this suggests that obesity may just be a proxy

那代表肥胖

只是問題的代理者

for what's going on.

So what if we're fighting the wrong war,

所以萬一我們打錯仗了

fighting obesity rather than insulin resistance?

我們對付肥胖的問題而非胰島素抗性

Even worse, what if blaming the obese

假如更糟的，會不會我們把問題歸咎於肥胖

means we're blaming the victims?

就是在責怪受害者呢

What if some of our fundamental ideas about obesity

會不會我們對肥胖症的

are just wrong?

基本觀念完全錯誤？

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

我個人無法再承受傲慢要付出的奢侈代價

let alone the luxury of certainty.

更別說下定論要付出的代價了

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

我對這個個問題有自己的一套想法

but I'm wide open to others.

但我也接受別人的想法

Now, my hypothesis, because everybody always asks me,

因為大家總會問，我的假設是什麼

is this.

是這樣子的

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

問問看自己，如果身體有胰島素抗性的時候

when it becomes insulin resistant,

細胞會試著遠離什麼東西

the answer probably isn't too much food.

答案絕對不是遠離過量的食物

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

而是遠離血液中過量的葡萄糖，也就是血糖

Now, we know that refined grains and starches

我們都知道精緻的穀物及澱粉

elevate your blood sugar in the short run,

會在短時間內提高血糖

and there's even reason to believe that sugar

我們甚至很有理由相信

may lead to insulin resistance directly.

就是糖分直接導致了胰島素抗性

So if you put these physiological processes to work,

所以這些生理過程

I'd hypothesize that it might be our increased intake

我推測是因為我們攝取了過多

of refined grains, sugars and starches that's driving

精緻穀物、糖分、澱粉

這些導致肥胖及糖尿病這類流行病的東西

this epidemic of obesity and diabetes,

but through insulin resistance,

但這是因為胰島素抗性造成的

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

而不是暴飲暴食或運動量不足所致

When I lost my 40 pounds a few years ago,

我前幾年減了40磅 (約18.14公斤)

I did it simply by restricting those things,

只是藉由少吃那些東西

which admittedly suggests I have a bias

這等於是承認我因為個人經驗

based on my personal experience.

而有所偏見

But that doesn't mean my bias is wrong,

但這不代表我的偏見是錯的

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

更重要的是，這些都能經過科學證實

But step one is accepting the possibility

但第一步是接受

that our current beliefs about obesity,

可能我們現在對於肥胖、糖尿病及胰島素抗性

diabetes and insulin resistance could be wrong

想法是錯的

and therefore must be tested.

因此還需要證實

I'm betting my career on this.

我以我的職業生涯為賭注

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

現在我將我所有時間投入於研究這個問題

and I'll go wherever the science takes me.

而我會依科學測試的結果來定論

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

我已經決定我沒有答案時

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

我不能假裝，也不會再去假裝我知道答案

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

我不知道的事已經足以讓我謙虛了

For the past year, I've been fortunate enough

過去一年，我很幸運

to work on this problem with the most amazing team

能和一個非常優秀的團隊一起工作

of diabetes and obesity researchers in the country,

他們是我國最有權威的 糖尿病及肥胖問題的研究人員

and the best part is,

最棒的是

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

就像林肯總統一樣，他選擇被一群對手圍繞

we've done the same thing.

我們也做同樣的事情

We've recruited a team of scientific rivals,

我們招募了一群最優秀的對手來組成科學團隊

the best and brightest who all have different hypotheses

他們對這個流行病的起因

for what's at the heart of this epidemic.

也各有不同的假設

Some think it's too many calories consumed.

有些人認為是因為消耗太多的卡路里

Others think it's too much dietary fat.

有些人認為是攝取過多膳食脂肪

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

有些人則認為是食用過量的 精緻穀物及澱粉所致

But this team of multi-disciplinary,

不過在這個多方訓練的團隊中

highly skeptical and exceedingly talented researchers

這些容易起疑又非常有才華的研究人員

do agree on two things.

都同意兩件事

First, this problem is just simply too important

第一，這個問題實在太重要了

to continue ignoring because we think we know the answer.

因此我們不能繼續忽略 以為我們知道問題的解答

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

第二，如果我們願意認錯

if we're willing to challenge the conventional wisdom

我們願意去挑戰傳統的觀念

with the best experiments science can offer,

應用科學上最頂尖的研究方法

we can solve this problem.

我們可以改善這個問題

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

我知道大家現在就想要有答案

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

一些實際行動及措施或飲食上的建議

eat this, not that —

該吃什麼，不該吃什麼

but if we want to get it right,

但如果我們想得到正確的答案

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

我們必須先經歷過更多嚴格的科學檢驗

before we can write that prescription.

才能給大家飲食上的建議

Briefly, to address this, our research program

簡單來說，為了解決這個問題，我們研究計畫

is focused around three meta-themes, or questions.

主要圍繞於三個重要的主題及問題

First, how do the various foods we consume

第一，我們攝取的各類食物

impact our metabolism, hormones and enzymes,

是如何影響我們的代謝、激素及酵素

and through what nuanced molecular mechanisms?

又是透過什麼細微的分子機制來影響的

Second, based on these insights,

第二，由我們的見解為基礎

can people make the necessary changes in their diets

人們是否能在飲食上做出必要的改善

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

是否能用安全又實際的方式來達成

And finally, once we identify what safe

最後，了解飲食上我們能夠

and practical changes people can make to their diet,

做出哪些安全且實際的改變之後

how can we move their behavior in that direction

我們又將如何使飲食習慣 朝正確的方向來改善

so that it becomes more the default

讓這樣的飲食習慣變成自然反應

rather than the exception?

而不是一個例外的選擇

Just because you know what to do doesn't mean

只是因為知道要做什麼

you're always going to do it.

並不代表我們就會這麼做

Sometimes we have to put cues around people

有時候我們必須給大家一些線索

to make it easier, and believe it or not,

讓這件事容易做到，不管你們相不相信

that can be studied scientifically.

這都是科學能夠證實的

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

我不知道這趟科學之旅會有什麼結局

but this much seems clear to me, at least:

但至少有件事我很清楚

We can't keep blaming our overweight and diabetic patients

我們不該再責備肥胖及糖尿病患者

like I did.

不該像我以前一樣

Most of them actually want to do the right thing,

他們大部分也想做對的決定

but they have to know what that is,

但是他們需要知道如何改善

and it's got to work.

而且是有效的改善方法

I dream of a day when our patients can

我夢想有一天我們的病人

shed their excess pounds

能減掉多餘的重量

and cure themselves of insulin resistance,

並治好胰島素抗性

because as medical professionals,

因為身為醫療專家

we've shed our excess mental baggage

我們已經卸下心中多餘的包袱

and cured ourselves of new idea resistance sufficiently

然後充分地改善自己曾對新理念 有所抵抗的行為

to go back to our original ideals:

而回歸到我們原本的理念

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

心胸開闊，當舊有的陳見不再正確的時候

when they don't appear to be working,

我們能有拋下它的勇氣

and the understanding that scientific truth isn't final,

了解科學事實不是最後一步

but constantly evolving.

而是應該不斷的研究

Staying true to that path will be better for our patients

堅持站在真理的道路上 能幫助我們的病患

and better for science.

對科學也有更大的好處

If obesity is nothing more than a proxy

如果肥胖症只不過是

代謝問題的代罪羔羊

for metabolic illness,

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

責怪他們有什麼好處呢

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

有時候我回想七年前

seven years ago.

在急診室的那晚

I wish I could speak with that woman again.

我希望我能再次跟那女士講話

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

我想跟她說我多麼對不起她

I'd say, as a doctor, I delivered

我會說，身為一位醫生，

the best clinical care I could,

我是盡全力的去照顧病人

but as a human being,

但身為一個人

I let you down.

我讓你失望了

You didn't need my judgment and my contempt.

你並不需要我的批判及輕視的眼光

You needed my empathy and compassion,

妳需要的，是我的同理心和憐憫之心

and above all else, you needed a doctor

最重要的是，妳需要的是一位醫生

who was willing to consider

他能夠了解或許不是 妳讓這個醫療體制失望

maybe you didn't let the system down.

Maybe the system, of which I was a part,

而是這個體制，我也參與其中的這個體制

was letting you down.

讓妳失望了

If you're watching this now,

如果妳正在看這部影片

I hope you can forgive me.

我希望妳能原諒我

(Applause)

(掌聲)