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  • 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.

    我還記得當我拉開隔簾看她時

  • I can still remember sort of that smell of rotting flesh

    那種肉體腐爛的味道

  • as I pulled the curtain back to see her.

    在場的人一致認為她病得很嚴重

  • And everybody there agreed this woman was very sick

    必須住院治療

  • and she needed to be in the hospital.

    這大家所認同的

  • That wasn't being asked.

    但他們問我的是另一個問題

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

    也就是,她需要截肢嗎

  • which was, did she also need an amputation?

    而當我回想起那一晚

  • Now, looking back on that night,

    我極度地希望當時

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

    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

    不亞於另一位 27 歲的新婚女士

  • I'd shown the 27-year-old newlywed

    她當晚三天前來到急診室

  • who came to the E.R. three nights earlier

    說她的下背部疼痛

  • with lower back pain

    後來診斷出是胰腺癌末期

  • that turned out to be advanced pancreatic cancer.

    她的情況我知道 我無法給她任何醫療幫助

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

    來挽救她的生命

  • that was actually going to save her life.

    那癌症已經末期了

  • The cancer was too advanced.

    但我有責任確保

  • But I was committed to making sure that

    盡量讓她維持在舒適的狀態

  • I could do anything possible to make her stay

    我幫她多加一件被子

  • more comfortable. I brought her a warm blanket

    給她一杯咖啡

  • and a cup of a coffee.

    也幫她父母親買咖啡

  • I brought some for her parents.

    但最重要的是,我不怪她

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

    因為顯然她並沒有做錯什麼事

  • because obviously she had done nothing

    害她變成這樣

  • to bring this on herself.

    但為什麼,幾天之後

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

    我站在同一間急診室

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

    決定這位糖尿病患者需要截肢時

  • that my diabetic patient did indeed need an amputation,

    對她卻持有輕蔑的態度?

  • why did I hold her in such bitter contempt?

    大家可以發現,和前三天那位女士不同

  • You see, unlike the woman the night before,

    這位女士有二型糖尿病

  • this woman had type 2 diabetes.

    她有肥胖的問題

  • She was fat.

    我們都知道這是因為吃太多

  • And we all know that's from eating too much

    而且運動量不足,沒錯吧

  • and not exercising enough, right?

    我的意思是這會有多難呢?

  • I mean, how hard can it be?

    低頭看著她躺在床上,我心想

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

    如果妳能多留意一點

  • if you just tried caring even a little bit,

    現在就不會處於這種情況

  • you wouldn't be in this situation at this moment

    一堆妳沒見過的醫生

  • with some doctor you've never met

    即將要幫妳截肢

  • about to amputate your foot.

    為什麼這樣批評她是合理的

  • Why did I feel justified in judging her?

    我想說我不知道

  • I'd like to say I don't know.

    但其實我明白

  • But I actually do.

    當時年少輕狂

  • You see, in the hubris of my youth,

    我以為我看透她這種人

  • I thought I had her all figured out.

    她吃太多,她運氣不好

  • She ate too much. She got unlucky.

    得了糖尿病,就這樣

  • She got diabetes. Case closed.

    諷刺的是當時

  • Ironically, at that time in my life,

    我在研究癌症

  • I was also doing cancer research,

    具體一點是黑色素瘤的免疫治療

  • immune-based therapies for melanoma, to be specific,

    在這個領域當中我被教導去質疑一切

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

    要挑戰所有假設

  • to challenge all assumptions

    然後盡可能用最高的科學標準來衡量

  • and hold them to the highest possible scientific standards.

    然而講到糖尿病這類疾病

  • Yet when it came to a disease like diabetes

    在美國,致命率比黑色素瘤高八倍

  • that kills Americans eight times more frequently than melanoma,

    我從來不質疑傳統的觀念

  • I never once questioned the conventional wisdom.

    我其實已經假設病理學中的先後順序

  • I actually just assumed the pathologic sequence of events

    已由科學證實

  • was settled science.

    三年後,我發現我大錯特錯

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

    但這一次我成了病人

  • But this time, I was the patient.

    儘管我每天運動3~4小時

  • Despite exercising three or four hours every single day,

    飲食也遵循食物金字塔的概念

  • and following the food pyramid to the letter,

    仍然體重暴增

  • I'd gained a lot of weight and developed something

    得了新陳代謝症候群

  • called metabolic syndrome.

    在座可能有些人有聽過

  • Some of you may have heard of this.

    我身體有了胰島素抗性

  • I had become insulin-resistant.

    你們可以把胰島素想成一種主激素

  • You can think of insulin as this master hormone

    它在我們進食後掌控身體相關的運作

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

    燃燒能量或儲存能量

  • whether we burn it or store it.

    行話我們叫做燃料分區

  • This is called fuel partitioning in the lingo.

    無法分泌足夠的胰島素有生命危險

  • Now failure to produce enough insulin is incompatible with life.

    胰島素抗性,顧名思義

  • And insulin resistance, as its name suggests,

    就是細胞開始

  • is when your cells get increasingly resistant

    急劇抗拒胰島素發揮它的功能

  • to the effect of insulin trying to do its job.

    一旦身體有了胰島素抗性

  • Once you're insulin-resistant,

    就會得糖尿病

  • you're on your way to getting diabetes,

    糖尿病就是你的胰腺

  • which is what happens when your pancreas

    無法產生足夠的胰島素 來跟上抗性的程度

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

    血糖開始升高

  • Now your blood sugar levels start to rise,

    然後一連串的病理事件

  • and an entire cascade of pathologic events

    開始失去控制因而導致心臟病

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

    癌症,甚至阿茲海默症

  • cancer, even Alzheimer's disease,

    或者像前幾年那位女士一樣截肢

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

    我受到驚嚇並開始徹底改善飲食習慣

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

    加加減減一些

  • adding and subtracting things most of you would find

    你們大部分會滿意外的食物

  • almost assuredly shocking.

    我瘦了 40 磅但奇怪的是我運動量有所減少

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

    你們猜也知道,顯然我不再過重

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

    更重要的是我的身體沒有胰島素抗性了

  • More importantly, I don't have insulin resistance.

    但最重要的是

  • But most important, I was left

    在這之後我有三個急迫的問題揮之不去

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

    為什麼這種事會發生在我身上

  • How did this happen to me if I was supposedly

    明明我做的應該都是對的事

  • doing everything right?

    如果對營養的傳統觀念不適用在我身上

  • If the conventional wisdom about nutrition had failed me,

    是不是可能對別人也不適用呢

  • was it possible it was failing someone else?

    因為這些問題

  • And underlying these questions,

    我幾乎開始瘋狂著迷

  • I became almost maniacally obsessed

    試著找出肥胖與胰島素抗性之間

  • in trying to understand the real relationship

    真正的關聯

  • between obesity and insulin resistance.

    現在大部分的研究人員相信

  • Now, most researchers believe obesity

    是肥胖導致身體產生胰島素抗性

  • is the cause of insulin resistance.

    所以邏輯上來講,要治療胰島素抗性

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

    就是減重對吧

  • you get people to lose weight, right?

    就是治療肥胖的問題

  • You treat the obesity.

    但如果正好相反呢

  • But what if we have it backwards?

    萬一根本不是肥胖導致胰島素抗性呢

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

    萬一其實是一個更嚴重的症狀

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

    而它只是眾所皆知的冰山一角而已呢

  • the tip of a proverbial iceberg?

    我知道這聽起來有點瘋狂,因為我們明顯地

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

    還在這肥胖問題的流行病之中,但讓我解釋一下

  • of an obesity epidemic, but hear me out.

    會不會其實肥胖是一種應對機制

  • What if obesity is a coping mechanism

    為了來面對潛藏於細胞中

  • for a far more sinister problem going on

    更嚴重的問題呢

  • underneath the cell?

    我不是說肥胖是好事

  • I'm not suggesting that obesity is benign,

    我想表達的是,兩個新陳代謝惡魔相較下

  • but what I am suggesting is it may be the lesser

    肥胖是次要的

  • of two metabolic evils.

    你可以把胰島素抗性想成

  • You can think of insulin resistance as the reduced capacity

    我們身體為燃料分區的能力下降了

  • of our cells to partition fuel,

    像我剛剛提到的

  • as I alluded to a moment ago,

    身體將我們攝取的卡路里

  • taking those calories that we take in

    適當的燃燒及儲存

  • and burning some appropriately and storing some appropriately.

    當我們身體出現胰島素抗性時

  • When we become insulin-resistant,

    體內的狀態失去平衡

  • the homeostasis in that balance deviates from this state.

    所以現在,當胰島素跟細胞說

  • So now, when insulin says to a cell,

    我要你燃燒更多能量

  • I want you to burn more energy

    超過細胞視為安全的程度

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

    細胞會說謝了我要把能量存起來

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

    但脂肪細胞缺少

  • And because fat cells are actually missing most of

    其他細胞中大部分複雜的機制結構

  • the complex cellular machinery found in other cells,

    它可能成了儲存能量最安全的地方

  • it's probably the safest place to store it.

    所以約7500萬美國人,我們大多

  • So for many of us, about 75 million Americans,

    對胰島素抗性的正常反應

  • the appropriate response to insulin resistance

    事實上都是存成脂肪細胞,而非相反的

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

    因為肥胖而產生胰島素抗性

  • getting insulin resistance in response to getting fat.

    其實兩者差別不大

  • This is a really subtle distinction,

    但其隱含的意義深遠

  • but the implication could be profound.

    想一想接下來這個的類比

  • Consider the following analogy:

    你的腳瘀青了

  • Think of the bruise you get on your shin

    因為不小心撞到咖啡桌

  • when you inadvertently bang your leg into the coffee table.

    當然瘀青讓你痛得要命,你也絕對

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

    不喜歡瘀青的顏色,但我們都知道

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

    瘀青本身不是問題

  • the bruise per Se is not the problem.

    事實上相反的,它對傷口是一個好的反應

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

    這些免疫細胞衝到受傷部位

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

    為了拯救破損細胞,而避免細胞感染

  • to salvage cellular debris and prevent the spread

    擴散到身體其他部位

  • of infection to elsewhere in the body.

    現在假如我們把瘀青當作問題所在

  • Now, imagine we thought bruises were the problem,

    我們發展出巨大的醫療機構及文化

  • and we evolved a giant medical establishment

    專門在研究如何治療瘀青

  • and a culture around treating bruises:

    遮瑕乳液、止痛藥和任何你講得出來的東西

  • masking creams, painkillers, you name it,

    而我們這段時間都忽略了一個事實

  • all the while ignoring the fact that people

    人的膝蓋還是會撞到咖啡桌

  • are still banging their shins into coffee tables.

    對症下藥會不會更好

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

    告訴大家要小心

  • telling people to pay attention

    進出客廳要注意咖啡桌

  • when they walk through the living room --

    而不是針對傷害做治療

  • rather than the effect?

    如果我們瞭解因果關係

  • Getting the cause and the effect right

    會讓世界變得不同

  • makes all the difference in the world.

    弄錯前因後果

  • Getting it wrong, and the pharmaceutical industry

    藥物產業的股東沒有損失

  • can still do very well for its shareholders

    但對瘀青的人沒有任何幫助

  • but nothing improves for the people with bruised shins.

    這是因果關係的問題

  • Cause and effect.

    所以我想表達的是

  • So what I'm suggesting is

    或許我們搞錯了

  • maybe we have the cause and effect wrong

    肥胖和胰島素抗性的因果關係

  • on obesity and insulin resistance.

    我們也許該問問自己

  • Maybe we should be asking ourselves,

    會不會是因為胰島素抗性而造成體重增加

  • is it possible that insulin resistance causes weight gain

    還有其它與肥胖有關的疾病

  • and the diseases associated with obesity,

    至少大部分的人是如此

  • at least in most people?

    會不會肥胖只是一個新陳代謝的反應

  • What if being obese is just a metabolic response

    用來對付更具威脅性的

  • to something much more threatening,

    潛在流行病

  • an underlying epidemic,

    而這流行病才是我們該擔心的問題

  • the one we ought to be worried about?

    我們來看看一些相關的案例

  • Let's look at some suggestive facts.

    我們知道美國有3000萬肥胖的人

  • We know that 30 million obese Americans

    並沒有胰島素抗性的症狀

  • in the United States don't have insulin resistance.

    順便一提,他們罹患疾病的風險

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

    不會比瘦的人還高

  • greater risk of disease than lean people.

    相反的,我們知道美國有600萬瘦的人

  • Conversely, we know that six million lean people

    有胰島素抗性

  • in the United States are insulin-resistant,

    順便跟你們說,他們有更高的風險

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

    會得到我剛剛提到的那些代謝疾病

  • for those metabolic diseases I mentioned a moment ago

    而且比那些相對肥胖的人機率更高

  • than their obese counterparts.

    我不懂為什麼,但有可能他們的情況

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

    是因為細胞沒有辦法理解

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

    多餘的能量該如何使用

  • the right thing to do with that excess energy.

    所以如果肥胖的人沒有胰島素抗性

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

    或者瘦的人卻有胰島素抗性

  • and you can be lean and have it,

    那代表肥胖

  • this suggests that obesity may just be a proxy

    只是問題的代理者

  • for what's going on.

    所以萬一我們打錯仗了

  • So what if we're fighting the wrong war,

    我們對付肥胖的問題而非胰島素抗性

  • fighting obesity rather than insulin resistance?

    假如更糟的,會不會我們把問題歸咎於肥胖

  • Even worse, what if blaming the obese

    就是在責怪受害者呢

  • means we're blaming the victims?

    會不會我們對肥胖症的

  • What if some of our fundamental ideas about obesity

    基本觀念完全錯誤?

  • are just wrong?

    我個人無法再承受傲慢要付出的奢侈代價

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

    更別說下定論要付出的代價了

  • let alone the luxury of certainty.

    我對這個個問題有自己的一套想法

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

    但我也接受別人的想法

  • but I'm wide open to others.

    因為大家總會問,我的假設是什麼

  • Now, my hypothesis, because everybody always asks me,

    是這樣子的

  • is this.

    問問看自己,如果身體有胰島素抗性的時候

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

    細胞會試著遠離什麼東西

  • when it becomes insulin resistant,

    答案絕對不是遠離過量的食物

  • the answer probably isn't too much food.

    而是遠離血液中過量的葡萄糖,也就是血糖

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

    我們都知道精緻的穀物及澱粉

  • Now, we know that refined grains and starches

    會在短時間內提高血糖

  • elevate your blood sugar in the short run,

    我們甚至很有理由相信

  • and there's even reason to believe that sugar

    就是糖分直接導致了胰島素抗性

  • may lead to insulin resistance directly.

    所以這些生理過程

  • So if you put these physiological processes to work,

    我推測是因為我們攝取了過多

  • I'd hypothesize that it might be our increased intake

    精緻穀物、糖分、澱粉

  • of refined grains, sugars and starches that's driving

    這些導致肥胖及糖尿病這類流行病的東西

  • this epidemic of obesity and diabetes,

    但這是因為胰島素抗性造成的

  • but through insulin resistance,

    而不是暴飲暴食或運動量不足所致

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

    我前幾年減了40磅 (約18.14公斤)

  • When I lost my 40 pounds a few years ago,

    只是藉由少吃那些東西

  • I did it simply by restricting those things,

    這等於是承認我因為個人經驗

  • which admittedly suggests I have a bias

    而有所偏見

  • based on my personal experience.

    但這不代表我的偏見是錯的

  • But that doesn't mean my bias is wrong,

    更重要的是,這些都能經過科學證實

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

    但第一步是接受

  • But step one is accepting the possibility

    可能我們現在對於肥胖、糖尿病及胰島素抗性

  • that our current beliefs about obesity,

    想法是錯的

  • diabetes and insulin resistance could be wrong

    因此還需要證實

  • and therefore must be tested.

    我以我的職業生涯為賭注

  • I'm betting my career on this.

    現在我將我所有時間投入於研究這個問題

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

    而我會依科學測試的結果來定論

  • and I'll go wherever the science takes me.

    我已經決定我沒有答案時

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

    我不能假裝,也不會再去假裝我知道答案

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

    我不知道的事已經足以讓我謙虛了

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

    過去一年,我很幸運

  • For the past year, I've been fortunate enough

    能和一個非常優秀的團隊一起工作

  • to work on this problem with the most<