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
er
around two 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
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 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 er 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 coffee brought some for her
parents
but more importantly you 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
er and determined that my diabetic
patient did indeed need an amputation
why did i hold her in such bitter
contempt
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 look down
at her in the bed i thought to myself if
you just try
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
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 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
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 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
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 over it
anymore more importantly i don't have
insulin resistance
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 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
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've taken
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
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
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 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
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
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 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 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 kind of 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 insulin
resistance
sorry obesity and diabetes but through
insulin resistance you see
and not necessarily through just
overeating and under exercising
now 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
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 multidisciplinary
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
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
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
that in a safe and practical way 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
i don't know how this journey's 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 you know 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
sometimes i think back to that night in
the er
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 um you know as a doctor i
delivered the best clinical care i could
but as a as a human being
i let you down you didn't need my
judgment
and my contempt you needed my
empathy and compassion
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 apart was letting you
down
if you're watching this now
i hope you can forgive me
you