I'll never forget that day back in the spring of 2006. I was a surgical resident at The Johns Hopkins Hospital, taking emergency call. I got paged by the E.R. around 2 in the morning to come and see a woman with a diabetic ulcer on her foot. I can still remember sort of that smell of rotting flesh as I pulled the curtain back to see her. And everybody there agreed this woman was very sick and she needed to be in the hospital. That wasn't being asked. The question that was being asked of me was a different one, which was, did she also need an amputation?
Nunca esquecerei ese día. Era a primavera de 2006. Eu era residente de cirurxía no Hospital Johns Hopkins, atendendo chamadas de urxencias. Chamáronme para unha urxencia ás 2 da mañá: unha muller cunha úlcera diabética no pé. Aínda lembro aquela especie de cheiro a carne podre mentres apartaba a cortina para vela. Todos coincidiamos en que estaba moi enferma e tiña que estar ingresada Nin se formulaba a pregunta. O que me estaban a preguntar era outra cousa: tamén precisa dunha amputación? Agora, mirando cara atrás, aquela noite,
Now, looking back on that night, I'd love so desperately to believe that I treated that woman on that night with the same empathy and compassion I'd shown the 27-year-old newlywed who came to the E.R. three nights earlier with lower back pain that turned out to be advanced pancreatic cancer. In her case, I knew there was nothing I could do that was actually going to save her life. The cancer was too advanced. But I was committed to making sure that I could do anything possible to make her stay more comfortable. I brought her a warm blanket and a cup of a coffee. I brought some for her parents. But more importantly, see, I passed no judgment on her, because obviously she had done nothing to bring this on herself. So why was it that, just a few nights later, as I stood in that same E.R. and determined that my diabetic patient did indeed need an amputation, why did I hold her in such bitter contempt?
gustaríame tanto crer que aquela noite a tratei coa mesma empatía e compaixón que mostrara cunha acabada de casar de 27 anos que chegara 3 noites antes con dor lumbar, que resultou ser cancro de páncreas avanzado. Sabía que non había nada que eu puidese facer que de verdade lle salvase a vida. O cancro estaba moi avanzado. Pero empeñeime en garantir que faría todo o posible para facer a súa estancia máis cómoda. Tróuxenlle un cobertor e unha cunca de café. Tamén para os seus pais. Pero sobre todo non a xulguei, xa que, obviamente, ela non fixera nada para provocar a súa situación. Entón, por qué só un par de noites máis tarde, cando, na mesma sala de urxencias, determinei que a miña paciente diabética si precisaba unha amputación, por que sentín ese desprezo amargo?
You see, unlike the woman the night before, this woman had type 2 diabetes. She was fat. And we all know that's from eating too much and not exercising enough, right? I mean, how hard can it be? As I looked down at her in the bed, I thought to myself, if you just tried caring even a little bit, you wouldn't be in this situation at this moment with some doctor you've never met about to amputate your foot.
Pois porque, ao contrario da muller da noite anterior, esta muller tiña diabetes tipo 2. Estaba gorda. E todos sabemos que iso é de comer de máis e non facer exercicio abondo, non si? Quero dicir, é tan difícil? Mentres a vía na cama, pensaba: se simplemente intentaras coidarte un pouco non estarías nesta situación agora, cun médico ao que nunca viras a punto de amputarche un pé.
Why did I feel justified in judging her? I'd like to say I don't know. But I actually do. You see, in the hubris of my youth, I thought I had her all figured out. She ate too much. She got unlucky. She got diabetes. Case closed.
Por que me sentín con dereito a xulgala? Gustaríame dicir que non o sei. Pero en realidade si que o sei. Co arrogancia da xuventude, pensei que o entendía. Comeu de máis. Tivo mala sorte. Ten diabetes. Caso pechado.
Ironically, at that time in my life, I was also doing cancer research, immune-based therapies for melanoma, to be specific, and in that world I was actually taught to question everything, to challenge all assumptions and hold them to the highest possible scientific standards. Yet when it came to a disease like diabetes that kills Americans eight times more frequently than melanoma, I never once questioned the conventional wisdom. I actually just assumed the pathologic sequence of events was settled science.
Ironicamente, naquela época na miña vida, tamén facía investigación sobre o cancro, en concreto, terapia inmunolóxica para o melanoma, e nese mundo que me ensinou a cuestionar todo, a desafiar as presuncións e levalas aos máis altos estándares científicos posibles. Con todo, cunha enfermidade como a diabetes que mata oito veces máis estadounidenses que o melanoma, nin unha vez cuestionei a sabedoría convencional. Asumín a secuencia patolóxica dos feitos como probada.
Three years later, I found out how wrong I was. But this time, I was the patient. Despite exercising three or four hours every single day, and following the food pyramid to the letter, I'd gained a lot of weight and developed something called metabolic syndrome. Some of you may have heard of this. I had become insulin-resistant.
Tres anos máis tarde, descubrín o equivocado que estaba. Esta vez, o paciente era eu. A pesar de facer exercicio tres ou catro horas todos os días, de seguir a pirámide alimentaria ao pé da letra, gañei moito peso e desenvolvín algo chamado síndrome metabólica. Algúns escoitarían falar dela. Fixérame resistente á insulina.
You can think of insulin as this master hormone that controls what our body does with the foods we eat, whether we burn it or store it. This is called fuel partitioning in the lingo. Now failure to produce enough insulin is incompatible with life. And insulin resistance, as its name suggests, is when your cells get increasingly resistant to the effect of insulin trying to do its job. Once you're insulin-resistant, you're on your way to getting diabetes, which is what happens when your pancreas can't keep up with the resistance and make enough insulin. Now your blood sugar levels start to rise, and an entire cascade of pathologic events sort of spirals out of control that can lead to heart disease, cancer, even Alzheimer's disease, and amputations, just like that woman a few years earlier.
Poden pensar na insulina como a hormona mestra que controla o que fai o noso corpo cos alimentos que comemos, queimalos ou almacenalos. Separación do combustible no argot. Non producir insulina suficiente é incompatible coa vida. E a resistencia á insulina, como o propio nome indica, é cando as células opoñen cada vez máis resistencia ao efecto da insulina tentando facer o seu traballo. Cando un é resistente á insulina, está no camiño a padecer diabetes, que é o que pasa cando o páncreas non pode superar a resistencia e producir insulina suficiente. Os niveis de azucre no sangue comezan a subir, e iniciase unha auténtica fervenza de eventos patolóxicos, unha espiral fóra de control, que pode levar a enfermidades cardíacas, cancro, mesmo alzheimer, e amputacións, como aquela muller uns anos antes.
With that scare, I got busy changing my diet radically, adding and subtracting things most of you would find almost assuredly shocking. I did this and lost 40 pounds, weirdly while exercising less. I, as you can see, I guess I'm not overweight anymore. More importantly, I don't have insulin resistance.
Con este susto, púxenme a cambiar a miña dieta radicalmente, poñendo e quitando cousas que a maioría seguramente atoparían chocantes. Fíxeno e perdín 18 quilos, sorprendentemente facendo menos exercicio. Como se pode ver, creo que xa non teño sobrepeso E sobre todo, tampouco resistencia á insulina.
But most important, I was left with these three burning questions that wouldn't go away: How did this happen to me if I was supposedly doing everything right? If the conventional wisdom about nutrition had failed me, was it possible it was failing someone else? And underlying these questions, I became almost maniacally obsessed in trying to understand the real relationship between obesity and insulin resistance.
Pero, o máis importante, quedei con estas tres cuestións candentes que non marchaban: Como me pasou isto se, en teoría, estaba facendo o correcto? A sabedoría convencional sobre nutrición fallárame. Estaríalle fallando a alguén máis? E, baixo estas preguntas, obsesioneime dun xeito case maníaco con tentar entender a relación real entre obesidade e resistencia á insulina.
Now, most researchers believe obesity is the cause of insulin resistance. Logically, then, if you want to treat insulin resistance, you get people to lose weight, right? You treat the obesity. But what if we have it backwards? What if obesity isn't the cause of insulin resistance at all? In fact, what if it's a symptom of a much deeper problem, the tip of a proverbial iceberg? I know it sounds crazy because we're obviously in the midst of an obesity epidemic, but hear me out. What if obesity is a coping mechanism for a far more sinister problem going on underneath the cell? I'm not suggesting that obesity is benign, but what I am suggesting is it may be the lesser of two metabolic evils.
A maioría dos investigadores consideran que a obesidade é a causa da resistencia á insulina. Por lóxica, se se quere tratar a resistencia á insulina, faise que a xente perda peso, non? Trátase a obesidade. Pero, e se imos ó revés? E se a obesidade non é para nada a causa da resistencia á insulina? E se, de feito, é un síntoma dun problema moito máis profundo, a punta dun iceberg proverbial? Sei que parece unha tolería, porque estamos, obviamente, no medio dunha epidemia de obesidade. Pero, escoiten. E se a obesidade é un mecanismo para afrontar un problema moito máis sinistro baixo todo isto? Non digo que a obesidade sexa benigna, o que digo é que pode ser o menor de dous males metabólicos. Poden ver a resistencia á insulina como a capacidade reducida
You can think of insulin resistance as the reduced capacity of our cells to partition fuel, as I alluded to a moment ago, taking those calories that we take in and burning some appropriately and storing some appropriately. When we become insulin-resistant, the homeostasis in that balance deviates from this state. So now, when insulin says to a cell, I want you to burn more energy than the cell considers safe, the cell, in effect, says, "No thanks, I'd actually rather store this energy." And because fat cells are actually missing most of the complex cellular machinery found in other cells, it's probably the safest place to store it. So for many of us, about 75 million Americans, the appropriate response to insulin resistance may actually be to store it as fat, not the reverse, getting insulin resistance in response to getting fat.
das nosas células para repartir o combustible, como dixen hai pouco, tomar esas calorías que inxerimos queimar algunhas e almacenar outras adecuadamente. Cando nos facemos resistentes á insulina, a homeostase deste equilibrio desvíase deste estado. Así, cando a insulina lle di a unha célula: Quero que queimes máis enerxía do que a célula considera seguro, a célula di: "Non, grazas, prefiro almacenar esa enerxía." E como as células de graxa carecen da maioría da complexa maquinaria atopada noutras células, seguramente sexan o lugar máis seguro para almacenala. Así, para moitos de nós, uns 75 millóns de estadounidenses, a resposta adecuada á resistencia á insulina pode ser almacenalo como graxa, e non ó contrario, desenvolver resistencia á insulina como resultado de engordar.
This is a really subtle distinction, but the implication could be profound. Consider the following analogy: Think of the bruise you get on your shin when you inadvertently bang your leg into the coffee table. Sure, the bruise hurts like hell, and you almost certainly don't like the discolored look, but we all know the bruise per Se is not the problem. In fact, it's the opposite. It's a healthy response to the trauma, all of those immune cells rushing to the site of the injury to salvage cellular debris and prevent the spread of infection to elsewhere in the body. Now, imagine we thought bruises were the problem, and we evolved a giant medical establishment and a culture around treating bruises: masking creams, painkillers, you name it, all the while ignoring the fact that people are still banging their shins into coffee tables. How much better would we be if we treated the cause -- telling people to pay attention when they walk through the living room -- rather than the effect? Getting the cause and the effect right makes all the difference in the world. Getting it wrong, and the pharmaceutical industry can still do very well for its shareholders but nothing improves for the people with bruised shins. Cause and effect.
É unha diferenza moi sutil, pero as implicacións poden ser profundas. Consideren a seguinte analoxía: Pensen nunha mazadura que se produce nunha canela, cando sen darse conta baten coa mesa do café, Por suposto, a lesión doe moitísimo, e seguramente non lle guste a aparencia descolorida, pero todos sabemos que a lesión en si non é o problema. En realidade, é o contrario. É unha resposta saudable ao trauma, todas as células inmunitarias correndo ó lugar da lesión para salvar os restos celulares e evitar a propagación da infección a outras partes do corpo. Agora imaxinen que pensásemos que as mazaduras eran o problema, e desenvolvésemos un sistema médico xigante, e unha cultura arredor do tratamento das mazaduras: cremas de enmascaramento, analxésicos, de todo, en todo momento ignorando o feito de que a xente segue a bater coas canelas nas mesas do café. Canto mellor sería se tratásemos a causa, --avisando á xente de que teña conta cando ande pola sala de estar-- en vez do efecto? Interpretar a causa e o efecto correctamente marca a diferenza por completo. Se o interpretamos incorrectamente, a industria farmacéutica aínda o estaría a facer moi ben para os seus accionistas pero nada mellora para as persoas con pernas moradas. Causa e efecto.
So what I'm suggesting is maybe we have the cause and effect wrong on obesity and insulin resistance. Maybe we should be asking ourselves, is it possible that insulin resistance causes weight gain and the diseases associated with obesity, at least in most people? What if being obese is just a metabolic response to something much more threatening, an underlying epidemic, the one we ought to be worried about?
O que eu suxiro é que, se cadra entendemos mal a relación causa-efecto entre a obesidade e a resistencia á insulina. Se cadra deberámonos preguntar, é posible que a resistencia á insulina cause o aumento de peso e as enfermidades asociadas coa obesidade, polo menos na maioría das persoas? E se ser obeso é só unha resposta metabólica a algo moito máis ameazante, unha epidemia subxacente, que é polo que deberiamos estar preocupados?
Let's look at some suggestive facts. We know that 30 million obese Americans in the United States don't have insulin resistance. And by the way, they don't appear to be at any greater risk of disease than lean people. Conversely, we know that six million lean people in the United States are insulin-resistant, and by the way, they appear to be at even greater risk for those metabolic diseases I mentioned a moment ago than their obese counterparts. Now I don't know why, but it might be because, in their case, their cells haven't actually figured out the right thing to do with that excess energy. So if you can be obese and not have insulin resistance, and you can be lean and have it, this suggests that obesity may just be a proxy for what's going on.
Vexamos uns feitos rechamantes. Sabemos que 30 millóns de estadounidenses obesos non teñen a resistencia á insulina. E, a propósito, non parecen ter maior risco de enfermidade que as persoas delgadas. Por outra banda, sabemos que seis millóns de persoas fracas nos Estados Unidos son insulinorresistentes, e, por certo, parecen presentar un risco aínda maior de padecer estas enfermidades metabólicas que mencionaba que os seus homólogos obesos. Non sei o porqué, pero podería ser porque neste caso, as células non descubriron o correcto que facer co exceso de enerxía. Entón, pódese ser obeso e non ter resistencia á insulina, e pódese estar delgada e tela. Isto suxire que a obesidade pode ser só un representante do que está sucedendo.
So what if we're fighting the wrong war, fighting obesity rather than insulin resistance? Even worse, what if blaming the obese means we're blaming the victims? What if some of our fundamental ideas about obesity are just wrong?
E se estamos loitando a guerra equivocada, a loita contra a obesidade, no canto da resistencia á insulina? Peor aínda, e se culpar ós obesos significa que estamos culpando ás vítimas? E se algunha das nosas ideas fundamentais sobre a obesidade están mal? Persoalmente, xa non me permito o luxo da arrogancia
Personally, I can't afford the luxury of arrogance anymore, let alone the luxury of certainty. I have my own ideas about what could be at the heart of this, but I'm wide open to others. Now, my hypothesis, because everybody always asks me, is this. If you ask yourself, what's a cell trying to protect itself from when it becomes insulin resistant, the answer probably isn't too much food. It's more likely too much glucose: blood sugar. Now, we know that refined grains and starches elevate your blood sugar in the short run, and there's even reason to believe that sugar may lead to insulin resistance directly. So if you put these physiological processes to work, I'd hypothesize that it might be our increased intake of refined grains, sugars and starches that's driving this epidemic of obesity and diabetes, but through insulin resistance, you see, and not necessarily through just overeating and under-exercising.
e moito menos o luxo da certeza. Teño as miñas propias ideas sobre isto, pero estou aberto a outras. A miña hipótese, porque todo o mundo ma pregunta é: Se te preguntas, de que se intenta protexer unha célula cando se fai resistente á insulina? a resposta probablemente non sexa: demasiada comida. Probablemente é a glicosa: azucre no sangue. Agora sabemos que os grans refinados e o amidón elevan o azucre no sangue a curto prazo. Hai incluso razóns para crer que o azucre poida levar á resistencia á insulina directamente. Se poñemos eses procesos fisiolóxicos a traballar, a miña hipótese é que é posible que o aumento na inxesta de grans refinados, azucres e amidón nos estea levando á epidemia de obesidade e diabetes, pero a través da resistencia á insulina, e non necesariamente por exceso de comida e falta de exercicio.
When I lost my 40 pounds a few years ago, I did it simply by restricting those things, which admittedly suggests I have a bias based on my personal experience. But that doesn't mean my bias is wrong, and most important, all of this can be tested scientifically. But step one is accepting the possibility that our current beliefs about obesity, diabetes and insulin resistance could be wrong and therefore must be tested. I'm betting my career on this. Today, I devote all of my time to working on this problem, and I'll go wherever the science takes me. I've decided that what I can't and won't do anymore is pretend I have the answers when I don't. I've been humbled enough by all I don't know.
Cando eu perdín os 18 quilos, fíxeno eliminando estas cousas, polo que admito que teño unha inclinación baseada na miña experiencia persoal. Pero iso non significa que o meu prexuízo sexa malo, e o máis importante, todo isto pode ser probado cientificamente. O primeiro paso é aceptar a posibilidade de que as nosas ideas actuais sobre obesidade, a diabetes e a resistencia á insulina poidan ser incorrectas e, polo tanto, deben ser comprobadas. Aposto a miña carreira nisto. Hoxe, dedico todo o meu tempo a traballar neste problema, e eu vou cara a onde a ciencia me leva. Decidín que o que nin podo nin vou facer máis é finxir que teño as respostas cando non as teño. Xa me humillei o suficiente con todo o que non sei.
For the past year, I've been fortunate enough to work on this problem with the most amazing team of diabetes and obesity researchers in the country, and the best part is, just like Abraham Lincoln surrounded himself with a team of rivals, we've done the same thing. We've recruited a team of scientific rivals, the best and brightest who all have different hypotheses for what's at the heart of this epidemic. Some think it's too many calories consumed. Others think it's too much dietary fat. Others think it's too many refined grains and starches. But this team of multi-disciplinary, highly skeptical and exceedingly talented researchers do agree on two things. First, this problem is just simply too important to continue ignoring because we think we know the answer. And two, if we're willing to be wrong, if we're willing to challenge the conventional wisdom with the best experiments science can offer, we can solve this problem.
No último ano, tiven a sorte de traballar neste problema co equipo máis incrible de investigadores en diabetes e obesidade de todo o país, e o mellor é que, tal como Abraham Lincoln se rodeara de rivais fixemos o mesmo. Xuntamos un equipo de científicos rivais o mellor e máis brillante entre os que teñen distintas hipóteses sobre o centro desta epidemia. Algúns pensan que é o exceso de calorías. Outros cren que é moita graxa na dieta. Outros pensan que é o exceso de grans refinados e amidón. Pero este equipo multidisciplinario de investigadores altamente escépticos e de gran talento, puxéronse de acordo en dous puntos. En primeiro lugar, este problema é demasiado importante para seguir ignorándoo, crendo que sabemos a resposta. E dous, se estamos dispostos a estar equivocados, a desafiar a sabedoría convencional, coas mellores probas científicas, podemos solucionar este problema.
I know it's tempting to want an answer right now, some form of action or policy, some dietary prescription -- eat this, not that — but if we want to get it right, we're going to have to do much more rigorous science before we can write that prescription.
Sei que é tentador querer unha resposta inmediata, algún tipo de acción ou política, algunha prescrición dietética --come isto, deixa isto-- pero se queremos facelo ben, imos ter que facer unha ciencia máis rigorosa antes de prescribir nada.
Briefly, to address this, our research program is focused around three meta-themes, or questions. First, how do the various foods we consume impact our metabolism, hormones and enzymes, and through what nuanced molecular mechanisms? Second, based on these insights, can people make the necessary changes in their diets in a way that's safe and practical to implement? And finally, once we identify what safe and practical changes people can make to their diet, how can we move their behavior in that direction so that it becomes more the default rather than the exception? Just because you know what to do doesn't mean you're always going to do it. Sometimes we have to put cues around people to make it easier, and believe it or not, that can be studied scientifically.
En resumo, para abordar isto, o noso programa de investigación está centrado arredor de tres piares. En primeiro lugar, como impacta o que consumimos no noso metabolismo, hormonas e encimas, e a través de que matices nos mecanismos moleculares? En segundo lugar, en base a estas ideas, a xente pode facer os cambios necesarios nas súas dietas de forma que sexa seguro e práctico facelo? E, finalmente, unha vez identificados os cambios prácticos e seguros como modificamos o noso comportamento para que isto se converta no corrente e non na excepción? Porque xa saben que saber o que se debe facer non sempre significa facelo. Ás veces hai que poñer pistas, para facelo máis doado, e créano ou non, isto pode estudarse cientificamente. Non sei como vai rematar esta viaxe
I don't know how this journey is going to end, but this much seems clear to me, at least: We can't keep blaming our overweight and diabetic patients like I did. Most of them actually want to do the right thing, but they have to know what that is, and it's got to work. I dream of a day when our patients can shed their excess pounds and cure themselves of insulin resistance, because as medical professionals, we've shed our excess mental baggage and cured ourselves of new idea resistance sufficiently to go back to our original ideals: open minds, the courage to throw out yesterday's ideas when they don't appear to be working, and the understanding that scientific truth isn't final, but constantly evolving. Staying true to that path will be better for our patients and better for science. If obesity is nothing more than a proxy for metabolic illness, what good does it do us to punish those with the proxy?
pero, polo menos para min, unha cousa está clara, Non podemos seguir culpando ós nosos pacientes con sobrepeso e diabéticos como fixen eu. A maioría deles queren facer o correcto, pero teñen que saber o que é, e así vai saír ben. Soño co día no que os pacientes, poidan perder os quilos de máis, e autocurarse da resistencia á insulina grazas a que os profesionais médicos deixamos o noso exceso de ideas preconcibidas e autocurámonos da resistencia ás novas ideas para volver ós nosos ideais orixinais: mente aberta, valor para tirar as ideas de onte cando parecen non funcionar, e entender que a verdade científica non é definitiva, se non que evoluciona constantemente. Manterse fiel a ese camiño será mellor para os pacientes, e mellor para a ciencia. Se a obesidade non é máis que un representante das enfermidades metabólicas, en que axuda castigar ao representante?
Sometimes I think back to that night in the E.R. seven years ago. I wish I could speak with that woman again. I'd like to tell her how sorry I am. I'd say, as a doctor, I delivered the best clinical care I could, but as a human being, I let you down. You didn't need my judgment and my contempt. You needed my empathy and compassion, and above all else, you needed a doctor who was willing to consider maybe you didn't let the system down. Maybe the system, of which I was a part, was letting you down. If you're watching this now, I hope you can forgive me.
Ás veces penso naquela noite en urxencias de hai sete anos. Gustaríame poder falar con aquela muller de novo. Gustaríame dicirlle cando o sinto. Diríalle que, como médico lle dei os mellores coidados que puiden, pero que como ser humano a decepcionei. Non precisabas nin o meu xuízo nin o meu desprezo. Precisabas empatía e compaixón e por riba de todo, precisabas un médico que estivese disposto a considerar que se cadra non eras ti a que lle estaba fallando ó sistema. Se cadra era o sistema, do que eu era parte, o que che estaba fallando. Se estás vendo isto, Espero que me poidas perdoar. (Aplausos)
(Applause)