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?
2006 年嘅春天 發生咗一件無辦法忘記嘅事 我當時係約翰斯 · 霍普金斯醫院 外科駐院醫生 負責急症 有朝凌晨兩點 急症室打嚟,叫我返去醫院 睇一個隻腳患咗糖尿病潰瘍嘅女病人 我到而家都仲記得拉開塊簾 聞到一陣潰爛味 所有人都認為呢位女士 病情嚴重,需要留醫 咁呢當然啦仲使問 但我當時仲有一個疑問 佢駛唔駛做切肢手術?
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?
而家,諗返嗰晚嘅事 我拼命令自己相信 我對待呢一位女病人嘅心 同對另一位女病人嘅心,都係一樣 第二位病人 27 歲、結婚冇耐 就喺第一位病人入嚟急症室前嘅三日 因為下腰痛嚟到急症室 結果驗出比較後期嘅胰腺癌 我知道我做唔到咩保住佢嘅性命 癌症已經好後期 但我仍然向佢保證 我會盡一切努力令佢更加舒服 我帶咗佢一張毯同一杯咖啡 我亦都帶咗啲畀佢父母 但更重要嘅係,我冇批評過佢 因為好明顯,佢患呢個病係無辜嘅 咁點解,幾晚之後,我喺同一間急症室 決定我嘅糖尿病人需要截肢? 點解我會咁樣睇低佢呢? 同第二位女病人唔同
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.
第一位病人有第二類糖尿病,而且肥胖 我哋都知道第二類糖尿病 係因為食太多 同唔夠運動引起,係咪? 我嘅意思係 食少啲同做運動有幾難呢? 我望住佢瞓喺床,心諗 如果你以前關心自己多啲 你而家就唔會俾醫生截肢 點解我會覺得咁樣評價佢係合理呢?
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.
我想答我唔知道 但我其實心裏面係有原因 你睇下,年輕嘅我幾咁傲慢 覺得自己好了解病人 認為病人因為食得太多,同埋唔好彩 所以患上糖尿病。完
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.
諷刺嘅係我當時做緊癌症研究 研究以免疫系統為本嘅黑色素瘤療法 研究裏面,我學到要凡事問問題 質疑所有假設 同埋將研究保持喺最高嘅科學標準 但講到一啲好似糖尿病咁嘅病 比黑色素瘤奪去多八倍美國人嘅病 我從未懷疑過前人知識 我假設咗以前讀到嘅 病理發展次序係成形嘅科學
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.
三年後,我終於明白自己有幾錯 但今次,我係一個病人 雖然我每日都會做三至四個鐘運動 並且不折不扣跟足食物金字塔 我嘅體重仍然增加 而且患上咗代謝症候群 可能在座有人會聽過呢個病 我個身體突然抗拒胰島素
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.
各位可以想像胰島素係一種主要激素 控制身體對食咗嘅食物作出反應 話畀身體知消耗定儲存食物 呢個生理反應叫能量分區 產生唔到足夠胰島素係難以令人生活 而抗胰島素,顧名思義 就係細胞對胰島素所做嘅嘢愈嚟愈抗拒 當你係抗胰島素,糖尿病就會埋你身 你嘅胰腺就會因為抗胰島素嘅關係 製造唔到足夠嘅胰島素 血糖於是會上升 然後病情就會失控 最終引致心臟病、癌症 阿爾茨海默氏病,同埋截肢 即係好似幾年前嗰位女士咁樣
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.
因為我好驚會變成咁 所以我徹底改變咗飲食習慣 飲食上開始食加同減一啲 大部分人會驚訝嘅嘢 做咗之後令我輕咗 40 磅 奇怪嘅係我做少咗運動 大家見到,我已經唔再超重
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.
更重要嘅係,抗胰島素無再發生 但最重要嘅係 我仲有三個急需解決嘅問題︰ 假如我嘅生活習慣係健康 咁點解呢個病係會發生喺我身上呢? 如果有關營養嘅舊有知識 對我唔適用嘅話 會唔會對其他人都係咁? 問咗呢啲問題之後 我更加想了解 肥胖同抗胰島素之間嘅真正關係
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.
如今,大部分學者都相信 肥胖係抗胰島素嘅原因 咁照邏輯推理,如果想醫好抗胰島素 我哋就要鼓勵啲人減肥,係咪? 所以我哋要醫肥胖 但係如果個關係調轉呢? 如果肥胖根本唔係抗胰島素嘅原因? 如果肥胖反映緊一個更深嘅問題? 我知咁講好似好癲 因為我哋都經歷梗肥胖流行病嘅爆發 但請先聽我講 如果肥胖係一個機制 畀我哋抵禦更加兇險嘅細胞問題? 我唔係講緊肥胖係好事 但我認為肥胖係兩種代謝問題之中 影響比較輕微嗰個
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.
你可以將抗胰島素諗成 細胞獲取能量嘅能力下降 就好似我頭先提到 當我哋攝取卡路里嘅時候 我哋會將部分消耗同部分儲存 當我哋患上抗胰島素時 消耗同儲存嘅平衡就會消失 宜家當胰島素同細胞講 「我要你消耗更多能量」 但因為細胞覺得消耗率大過安全水平 所以會話「唔駛啦,我會蓄能量」 而由於脂肪細胞欠缺 其他細胞大部分複雜嘅細胞機制 所以佢哋係一個安全嘅地方儲存能量 所以對於我哋好多美國人嚟講 即係七千五百萬人嚟講 對抗胰島素最合適嘅做法 反而係我哋儲存脂肪 而唔係因為肥胖所以有抗胰島素
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.
呢兩個次序雖然分別唔大,但意義深遠 大家嘗試諗下以下比喻: 當你唔小心俾茶几撞到隻腳時 皮膚會有瘀傷 當然,瘀傷係好痛 你亦都唔會鍾意變咗色嘅皮膚 但我哋知道瘀傷唔係問題 相反,佢係對創傷嘅一個健康反應 所有免疫細胞趕去受傷嘅地方 阻止細胞殘骸擴散 同埋防止身體其他部位受到感染 而家,假設我哋覺得瘀傷係一個問題 而且研發到一種醫學技術 同埋形成一種文化去治療瘀傷 當中包括有掩蔽霜、止痛藥 各種你哋諗到嘅嘢都有 但係我哋忽略咗 人仍然會撞到茶几呢個事實 如果我哋根治呢個原因 叫人喺客廳行嘅時候小心啲 而唔係對付個後果 你話係咪好得多呢? 搞清原因同後果,世界從此會好唔同 攪錯咗嘅話 醫藥行業可以仍然會發展得好好 但人嘅小腿嘅瘀傷點都唔會有改善 講到因果關係
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?
所以我要講嘅係 可能我哋攪錯咗 肥胖同抗胰島素嘅因果關係 我哋可能要問問自己 喺至少大部分人當中 抗胰島素有冇可能導致肥胖 同各種同肥胖相關嘅疾病呢? 肥胖會唔會只係一樣 對更有威脅嘅嘢嘅反應呢? 例如隱性病 咁我哋需唔需要擔心呢? 我哋睇下一啲事實
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.
有三千萬肥胖嘅美國人係無抗胰島素 佢哋唔會比瘦嘅人有更大嘅疾病風險 相反,美國有六百萬瘦嘅人有抗胰島素 佢哋比肥胖嘅人更加易患上 剛才提及嘅代謝性疾病嘅風險 我唔知原因,但有可能因為 佢哋嘅細胞唔知點樣應對多咗嘅能量 所以,當人可以肥胖而無患上抗胰島素 而你瘦嘅人都可以患上抗胰島素嘅話 肥胖可以推斷只係一個身體狀態嘅訊號 如果我哋醫錯咗
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?
剩係醫肥胖而唔係醫抗胰島素 咁會有咩後果? 更差嘅係,如果肥胖嘅人 其實係受害者嘅話 咁點算呢? 如果我哋對肥胖嘅認識根本係錯架呢?
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.
個人嚟講,我承受唔起自大嘅後果 更受唔起做事絕對嘅後果 我對呢件事有我自己一套睇法 但我亦都樂意聽其他人意見 由於每個人都問我 所以我會講講我嘅假定 如果你問我 當一個細胞抵抗胰島素嘅時候 究竟佢係遠離緊啲咩 答案應該唔係過多嘅食物 而係過多嘅葡萄糖 ,亦即係血糖 我哋知道加工嘅穀物同澱粉 會短時間內增加血糖 而且有理由相信 糖份可能會直接導致抗胰島素 所以,如果思考整個生理過程 我會假設增加攝取 加工穀物、糖份同埋澱粉 會透過抗胰島素嘅現象 導致肥胖同埋糖尿病 而唔一定剩關食過多同太少運動
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.
幾年前,我只係控制食量同運動量 我就輕咗 40 磅 我承認呢一個係偏見嚟 因為係我嘅個人經歷 但咁樣唔代表我嘅偏見係錯 最重要係,全部嘢都可經得起科學驗證 不過首要接受 我哋現有對肥胖、糖尿病 同埋抗胰島素嘅觀念可能係錯 所以呢啲觀念都要驗證埋 我亦為呢樣嘢賭上我嘅生涯 今日,我用我所有時間去研究呢個問題 我會跟著科學嘅指引去做 當我決定無辦法或者唔去做一件事 其實係假扮知道答案 我對於唔知嘅嘢一直好謙虛 過去嘅一年裡面,我好幸運
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.
能夠同國內最優秀嘅 研究糖尿病同肥胖嘅團隊 共同探索呢一個問題 最美好嘅部分係我哋好似林肯咁 被同時係競爭對手嘅隊員包圍 我哋其實請嚟一班最頂尖最優秀 又對呢一個病各有見解嘅科學團隊 其中有啲認為原因係攝取過多卡路里 有啲認為係飲食高脂 有啲認為係進食太多加工嘅穀物和澱粉 呢個團隊雖然嚟自多個範疇 又有好高批判能力同又係好叻 但佢哋同意兩樣嘢 第一,因為我哋以為知道答案 所以可以繼續忽視呢個重要問題 第二,如果我哋願意接受自己係錯 並且願意利用最好嘅科學實驗 去挑戰舊有概念 我哋就可以解決問題
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.
我哋都好想即刻有一個答案 雖然宜家有各種形式嘅行動同政策 同埋一啲飲食配方 例如食呢樣,唔好食嗰樣 但如果我哋真係想對症下藥 我哋喺處方之前 我哋需要更嚴格嘅科學校證 簡單嚟講,我哋嘅研究計劃
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.
針對三個大主題或者問題 第一,我哋食嘅各種食物點樣 透過精密嘅的分子機制 影響新陳代謝、激素同埋酶呢? 第二,根據以上答案 人可唔可以對飲食習慣 作出安全而又實際嘅改變呢? 最後,當我哋搵到安全又實際嘅 飲食習慣畀人去跟嘅時候 我哋點樣普及呢一批人嘅行為 而唔係畀人覺得係另類嘅一群呢? 我哋知道應該去做咩嘢 唔代表我哋會做 有時候,我哋需要引導人 令研究更加科學化地進行 我唔知呢一個旅程嘅終點係點
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?
但最少有一件事係好清楚 就係我哋唔可以好似我以前咁 鬧嗰啲過重同埋患上糖尿病嘅人 佢哋大部分人都想糾正自己 但佢哋需要知道方向點樣行 同埋方向係要可行 我夢想有一日我哋嘅病人 能夠卸下過重嘅罪名 同埋醫好佢哋嘅抗胰島素 因為作為醫學專家 我哋已經卸下心理包袱 同埋醫好咗抗拒新見解嘅毛病 我哋返返去我哋原本嘅理想: 開放諗法 當昨日嘅觀念唔再啱用 就要有勇氣捨棄昨日嘅觀念 同埋要明白科學無永遠嘅事實 而係不斷演變緊嘅 緊守呢個諗法對我哋病人 同埋科學都有好處 如果肥胖只係代謝性疾病嘅徵兆 懲罰呢啲有徵兆嘅人 對我哋有咩好處呢?
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.
有時我會諗返起七年前 喺急症室嗰一晚 我好想再同嗰一位女士傾偈 我想同佢講我有幾咁內疚 我會講,作為一個醫生 我提供咗最好嘅臨床護理 但作為一個普通人 我令到你失望 你唔需要我嘅批評同埋蔑視 你需要嘅係我嘅同情同憐憫 除此之外,你仲需要一個醫生 佢願意考慮︰ 未必係你令社會失望 而係個社會,包括我在內,令你失望 如果你而家睇緊呢一個講座 希望你會原諒我 (掌聲)
(Applause)