back in the spring of 2006.

那天 2006年的春天。

I was a surgical resident

我還是一個外科住院醫生

at The Johns Hopkins Hospital,

在約翰霍普金斯醫院

taking emergency call.

應對急救電話

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

大約淩晨兩點左右我被急診室叫去

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.

足部潰瘍

I can still remember sort of that smell of rotting flesh

我至今還能記得聞到的那種肉類腐爛的味道

as I pulled the curtain back to see her.

當我拉開簾子看到她之後

And everybody there agreed this woman was very sick

顯而易見這位女士病得很重

and she needed to be in the hospital.

她需要住院治療

That wasn't being asked.

這是毫無疑問的

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

但那時我考慮的是另一個問題

which was, did she also need an amputation?

那就是，她需要截肢嗎？

Now, looking back on that night,

現在，回想起那夜，

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

我很後悔那天夜裡面對那位女士時

on that night with the same empathy and compassion

心中沒有帶著同樣的同情與悲憫

I'd shown the 27-year-old newlywed

三天前的夜裡一位27歲的新娘

who came to the E.R. three nights earlier

就像我平時面對其他病人那般

with lower back pain

因為下背疼痛來看急診

that turned out to be advanced pancreatic cancer.

後來她被診斷為晚期胰腺癌

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

雖然我知道我對她無能為力

that was actually going to save her life.

沒辦法救她

The cancer was too advanced.

癌症已經是末期了

But I was committed to making sure that

但我還是盡我所能的

I could do anything possible to make her stay

做了所有能讓她

more comfortable. I brought her a warm blanket

舒服一點的事情 我幫她找了條毛毯

and a cup of a coffee.

端了杯咖啡

I brought some for her parents.

給她父母送咖啡

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

更重要的是，我一點也不覺得這姑娘有錯

because obviously she had done nothing

很明顯一點責任也沒有

to bring this on herself.

她對自己的病

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

但是為什麼，僅僅過了幾夜

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

當我站在同一個急救室並且決定

that my diabetic patient did indeed need an amputation,

我的這位元糖尿病病人需要截肢手術時

why did I hold her in such bitter contempt?

為什麼我的心中帶著蔑視呢？

You see, unlike the woman the night before,

你看，跟那位新娘不一樣

this woman had type 2 diabetes.

這位女士有II型糖尿病

She was fat.

她很胖

And we all know that's from eating too much

而且我們都知道肥胖源自

and not exercising enough, right?

無節制的飲食和缺乏運動，對吧？

I mean, how hard can it be?

我的意思是，節食和運動很難嗎？

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

我看著她躺在床上，我心說

if you just tried caring even a little bit,

哪怕你稍微注意一點兒自己的身體

you wouldn't be in this situation at this moment

你也絕不會落到這步田地

with some doctor you've never met

跟一個你從未見過的醫生

about to amputate your foot.

一個即將給你截肢的醫生

Why did I feel justified in judging her?

為什麼當時我能心安理得的責備她呢？

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

我希望我不知道原因。

But I actually do.

但是說真的，我知道

You see, in the hubris of my youth,

你看，我那時年少輕狂

I thought I had her all figured out.

我自以為是的覺得她肯定就是我想到那樣。

She ate too much. She got unlucky.

她飲食無度，她運氣不好

She got diabetes. Case closed.

她得了糖尿病，基本就是這個情況。

Ironically, at that time in my life,

諷刺的是，就在那會兒

I was also doing cancer research,

我正在參與癌症的研究

immune-based therapies for melanoma, to be specific,

黑色素瘤的細胞免疫力療法，具體來說

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

在那個領域裡，我被教著去質疑一切

to challenge all assumptions

挑戰一切固有的理論成果

and hold them to the highest possible scientific standards.

並且在研究中嚴格遵守最高的科研準則。

Yet when it came to a disease like diabetes

但當我面對糖尿病

that kills Americans eight times more frequently than melanoma,

這種致死幾率高於黑色素瘤八倍的疾病時候

I never once questioned the conventional wisdom.

我從未質疑過傳統的理論

I actually just assumed the pathologic sequence of events

我當時真的認為糖尿病的發病機理

was settled science.

早有定論

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

三年以後，我發現我錯了。

But this time, I was the patient.

但是這次，我自己成了病人

Despite exercising three or four hours every single day,

儘管我每天運動三四個小時

and following the food pyramid to the letter,

嚴格遵守健康食譜

I'd gained a lot of weight and developed something

我還是體重激增並且得了

called metabolic syndrome.

代謝綜合征

Some of you may have heard of this.

你們也許有人聽說過它

I had become insulin-resistant.

我的身體對胰島素產生了抗性

You can think of insulin as this master hormone

你們可以把胰島素想像成一種荷爾蒙

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

它能控制我們的身體對攝入的食物做出反應

whether we burn it or store it.

消耗或是儲存它們

This is called fuel partitioning in the lingo.

在術語中稱之為燃料分區

Now failure to produce enough insulin is incompatible with life.

缺乏足夠的胰島素是很要命的

And insulin resistance, as its name suggests,

胰島素抵抗，就像字面上意思一樣

is when your cells get increasingly resistant

意味著你的細胞變得越來越不受

to the effect of insulin trying to do its job.

胰島素的指揮正常運作

Once you're insulin-resistant,

一旦你出現胰島素抵抗的情況

you're on your way to getting diabetes,

你離患糖尿病就不遠了

which is what happens when your pancreas

因為胰島素抵抗的緣故

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

你無法製造足夠的胰島素

Now your blood sugar levels start to rise,

你的血糖開始升高

and an entire cascade of pathologic events

一系列的病例症狀

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

會突然爆發並且可能導致心臟病

cancer, even Alzheimer's disease,

癌症，甚至老年癡呆症

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

或者截肢，就像幾年前的那位女士一樣

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

我很害怕，我很快改了食譜

adding and subtracting things most of you would find

做了一些的改變得益於新的食譜

almost assuredly shocking.

讓大家覺得不可思議

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

儘管我鍛煉得少了，我還是減掉了40磅

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

你們可以看到，我現在沒有超重

More importantly, I don't have insulin resistance.

更重要的是，我沒有胰島素抵抗症了

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:

三個亟待解決的問題

How did this happen to me if I was supposedly

為什麼這件事發生在我身上呢?

doing everything right?

我已經盡力做到無懈可擊了。

If the conventional wisdom about nutrition had failed me,

如果傳統的營養理論在我身上失效了

was it possible it was failing someone else?

在其他人身上會怎樣呢？

And underlying these questions,

通過對考慮這些問題

I became almost maniacally obsessed

我著了魔一樣的

in trying to understand the real relationship

真正的關係

between obesity and insulin resistance.

希望找到肥胖和胰島素之間

Now, most researchers believe obesity

現在，主流觀點認為

is the cause of insulin resistance.

肥胖導致了胰島素抵抗

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

依邏輯來說，如果你想治療胰島素抵抗

you get people to lose weight, right?

你必須減肥，對吧？

You treat the obesity.

先對付肥胖。

But what if we have it backwards?

但是如果我們反過來想一下？

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

假如肥胖並不會導致胰島素抵抗？

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

實際上，假如它只是一個徵兆一個更深層次的問題

the tip of a proverbial iceberg?

的冰山一角？

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

這聽起來很瘋狂因為我們很正身處

of an obesity epidemic, but hear me out.

一個肥胖症氾濫的時代，不過請耐心聽我解釋

What if obesity is a coping mechanism

假如肥胖是身體的某種應對機制

for a far more sinister problem going on

用來對付一個潛藏在細胞深處

underneath the cell?

更加兇險的問題？

I'm not suggesting that obesity is benign,

我不認為肥胖是無害的

but what I am suggesting is it may be the lesser

但是我覺得肥胖在兩種新陳代謝疾病中

of two metabolic evils.

是比較次要的那個

You can think of insulin resistance as the reduced capacity

大家可以把胰島素抵抗症看作

of ourselves to partition fuel,

我們身體燃料箱變小了

as I alluded to a moment ago,

就像我剛剛假設的那樣

taking those calories that we take in

正常情況下我們攝入的熱量

and burning some appropriately and storing some appropriately.

會被適量消耗並且適量儲存

When we become insulin-resistant,

當我們得了胰島素抵抗的時候

the homeostasis in that balance deviates from this state.

這個平衡就會偏離正常情況

So now, when insulin says to a cell,

於是乎，當胰島素告訴細胞

I want you to burn more energy

我需要你消耗一些能量

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

假如 細胞認為消耗太大，那些細胞就會回應到

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

“不了，我更想把這些能量儲存起來。”

And because fat cells are actually missing most of

因為脂肪細胞不同於其它細胞

the complex cellular machinery found in other cells,

它沒有那麼多複雜的結構和組織

it's probably the safest place to store it.

所以能量都被儲藏在那

So for many of us, about 75 million Americans,

因此對我們中許多人，大約7500萬

the appropriate response to insulin resistance

美國人來說 胰島素抵抗應被視作

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.

將胰島素抵抗歸因於肥胖。

This is a really subtle distinction,

這雖然是個相當微妙的區別

but the implication could be profound.

但是它的含義卻是相當深刻的

Consider the following analogy:

舉個例子來說，

Think of the bruise you get on your shin

想像一下你小腿上的烏青，

when you inadvertently bang your leg into the coffee table.

那是你不小心撞上咖啡桌時留下的

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

毫無疑問，這瘀青疼得要命

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

而且你肯定不喜歡腿上多個斑，但是我們都知道

the bruise per se is not the problem.

瘀青本身並不是個問題

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

恰恰相反，這是對外傷的一個正常生理反應

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

所有的免疫細胞都會迅速前往受傷的部位

to salvage cellular debris and prevent the spread

去清理壞死細胞的碎片並且防止

of infection to elsewhere in the body.

感染擴散到身體其他部位

Now, imagine we thought bruises were the problem,

好了，想像一下如果我們把烏青當作一個問題

and we evolved a giant medical establishment

我們發展出了一個龐大的醫療體系

and a culture around treating bruises:

以及文化來對待瘀青：

masking creams, painkillers, you name it,

遮蔽霜，止疼藥，等等

all the while ignoring the fact that people

而所有這一切都掩蓋了一個事實

are still banging their shins into coffee tables.

那就是人們依舊會撞到咖啡桌

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

如果我們可以從問題的根源入手

telling people to pay attention

告訴人們注意一下

when they walk through the living room --

從客廳走過的時候小心咖啡桌

rather than the effect?

這會比處理撞傷來的有效果的多

Getting the cause and the effect right

正確理解事情的表像和本因

makes all the difference in the world.

將使這個世界產生巨大的不同

Getting it wrong, and the pharmaceutical industry

即使治標不治本，製藥行業

can still do very well for its shareholders

依舊可以為股東們帶來利潤，

but nothing improves for the people with bruised shins.

但是對於受傷的人們來說，這沒有任何幫助

Cause and effect.

原因及結果

So what I'm suggesting is

所以我想指出的是

maybe we have the cause and effect wrong

在我們討論肥胖和胰島素抵抗的問題時

on obesity and insulin resistance.

把原因和結果弄反了

Maybe we should be asking ourselves,

也許我們需要問問我們自己了，

is it possible that insulin resistance causes weight gain

有沒有可能胰島素抵抗導致了體重增加

and the diseases associated with obesity,

以及隨肥胖帶來的併發症

at least in most people?

至少對於大多數人來說

What if being obese is just a metabolic response

有沒有可能肥胖只是胰島抵抗的一個代謝反應

to something much more threatening,

相較於其他更大的威脅

an underlying epidemic,

例如一些相關的疫病

the one we ought to be worried about?

它們才是我們真正應該去擔心的

Let's look at some suggestive facts.

讓我們來看些有暗示性的建議

We know that 30 million obese Americans

我們知道有3千萬肥胖症患者

in the United States don't have insulin resistance.

在美國並未患胰島素抵抗

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

同時，沒有證據顯示他們

greater risk of disease than lean people.

比非肥胖症患者更容易貽患其他疾病

Conversely, we know that six million lean people

恰恰相反，有6百萬非肥胖症患者

in the United States are insulin-resistant,

在美國存在胰島素抵抗，

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

而他們卻被證實易患

for those metabolic disease I mentioned a moment ago

那些我之前提到的糖尿病併發症

than their obese counterparts.

同時幾率較肥胖人士來的更高

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

雖然現在我還不知道為什麼，但是一個可能的原因是

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

對他們而言，他們的細胞無法正確的

the right thing to do with that excess energy.

對體內多餘能量做出反應

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

你可以是肥胖症患者，卻沒患胰島素抵抗，

and you can be lean and have it,

或者你可以不肥胖，卻患有胰島素抵抗

this suggests that obesity may just be a proxy

這都表明肥胖只不過是一個表徵 而胰島素抗拒才是根源。

for what's going on.

所以如果我們鬥爭搞錯了物件

So what if we're fighting the wrong war,

我們一直與肥胖戰鬥著

fighting obesity rather than insulin resistance?

而非胰島素抵抗？

Even worse, what if blaming the obese

而且更糟的是，如果指責過胖者

means we're blaming the victims?

其實確是在指責胰島素抵抗的受害者？

What if some of our fundamental ideas about obesity

如果我們對於肥胖症的一些基本認識本身

are just wrong?

就存在誤差？

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

就我個人而言，我沒有辦法繼續保持傲慢的態度

let alone the luxury of certainty.

讓我把那種過剩的確信感放在一邊

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

對於這些問題的核心為何，我有我自己的認識

but I'm wide open to others.

同時我也願意將它與其他人分享

Now, my hypothesis, because everybody always asks me,

我的假設，因為老有人問我

is this.

是這樣的

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

試問，一個細胞到底在畏懼什麼

when it becomes insulin resistant,

當它處於胰島素抗拒狀態時

the answer probably isn't too much food.

問題的答案可能不是攝入過多的食物

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

答案更有可能是攝入過量葡萄糖而導致血糖過高

Now, we know that refined grains and starches

精製的穀物和澱粉

elevate your blood sugar in the short run,

將在短時間內抬到你的血糖含量

and there's even reason to believe that sugar

而且我們有理由相信

may lead to insulin resistance directly.

糖分將直接導致胰島素抵抗症

So if you put these physiological processes to work,

所以如果把這些生理過程也列入考慮，

I'd hypothesize that it might be our increased intake

我認為是大量的不斷攝入

of refined grains, sugars and starches that's driving

精製穀物，糖類以及澱粉類食物導致了

this epidemic of obesity and diabetes,

肥胖症和糖尿病的流行，

but through insulin resistance,

但其病因是胰島素抵抗症

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

而不是由於暴飲暴食以及缺乏運動。

When I lost my 40 pounds a few years ago,

在我幾年前減去40磅時，

I did it simply by restricting those things,

我只是簡單的限制了精製穀物，糖，和澱粉的攝入，

which admittedly suggests I have a bias

誠然這也表明我存在一些偏見，

based on my personal experience.

而這些主要源自我的個人經驗。

But that doesn't mean my bias is wrong,

但是這並不意味著我的偏見是錯誤的，

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

更重要的是，所有這些偏見都是可以被科學驗證的

But step one is accepting the possibility

但是第一步就是要接受一種可能性

that our current beliefs about obesity,

那就是我們當前關於肥胖症，

diabetes and insulin resistance could be wrong

糖尿病以及胰島素抗拒症的理解可能存在偏差

and therefore must be tested.

並需要被驗證

I'm betting my career on this.

我把我的事業都賭在了這個可能性上

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

現在，我把所有的時間花在了這個問題的研究上，

and I'll go wherever the science takes me.

而且我將不會停止知道找到真正的答案

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

我已經決定有一件事是我不能也不會再做的，

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

那就是在我不知道答案的時候卻假裝知道

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

對所有我不知道的事情，我都相當謙虛