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<