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 2:00 in the morning to come and
see a woman with a diabetic ulcer on her
foot 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 loved 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
pass 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
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 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 an insulin resistance as its
name suggests is when your cells get
increasingly resistant to the effect of
insulin trying to do its job
once your 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 and
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 in 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 6 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 that 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's 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
you see if you
about it for a moment and this was
touched on last night 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 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 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 you know it's 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 a part was letting you
down if you're watching this now I hope
you can forgive me
you