Translator: Iris Xholi Reviewer: Helena Bedalli I will never forget that day of the spring of 2006. Isha resident surgeon at Johns Hopkins Hospital on receipt of emergency calls. Around 2am I was notified by ER to go see a woman with diabetic ulcer at her feet. I still remember that kind of rotten blood smell, so I was pulling the curtain to see him. We all there thought that woman was very sick and needed to be hospitalized. This was not in question. The question I was asking was another, did she need amputation? Now, turning our heads back to us that night I would desperately want to believe I treated that woman, that night, with the same empathy and compassion that I told to the 27-year-old newly married which came to the ER three days before with low back pain which turned out to be advanced pancreatic cancer. In her case, I knew there was nothing I could do that would save his life. The cancer was very advanced. But I was committed to making sure that I would do everything possible to make it feel more comfortable.
I brought her a warm blanket and a cup of coffee. I also brought it for her parents. But look, the most important thing is that I did not prejudge him, for it was evident that she had done nothing that could cause this to herself. Then, how is it possible that a few nights later, to stay in the same emergency room and set that my diabetic patient needed amputation, why did I say this in such a bitter way? The difference is that unlike the woman of the night before, this woman was suffering from type 2 diabetes. She was healthy. And we all know that this comes as a result of eating too much and lack of physical activity, right? I mean, how hard can it be? As I watched him lie down, I thought to myself, as if you cared very little, you would not be in this state now with a doctor you had never seen before preparing to cut your leg. Why did I feel justified in judging her? I would like to say that I do not know. But this is not true.
With the pride of my youth, I thought I had psychologized him. She has eaten a lot. She has been unlucky. I got diabetes. That’s the job. Strangely, at the time, I was researching about cancer, immune system therapies for skin cancer, to be more precise, from where I had learned that I should have doubts about everything, not to take anything for granted and you measure with the highest scientific standards. Meanwhile, when it comes to diabetes which kills 8 times more Americans than melanoma, I never tested the knowledge until then. I accepted you well, any link in the chain of pathological causes that leads to it. Three years later, I discovered I was very wrong. But this time, I was patient. Although I exercise 3-4 hours a day, and the implementation of the food pyramid with precision, I had gained a lot of weight and had developed something called metabolic syndrome. Some of you may have even heard of it.
I was immune to insulin. You can think of insulin as this omnipotent hormone that controls what our body does with the foods we eat, if we store them or burn them. In medical language this is called “energy sharing”. Insufficient insulin production is not compatible with life. And insulin resistance, as the name suggests, occurs when cells become more and more resistant from the effects of insulin trying to do its job. When you become insulin resistant, you become diabetic, what happens when the pancreas can not withstand resistance and produce enough insulin. The increase in the amount of sugar in the blood starts, and a waterfall of pathological problems get out of control, which can lead to heart problems, cancer, or even Alzheimer’s, and amputation, just like that woman a few years ago. With this problem, I started to change my diet drastically, removing and adding things you would find obviously shocking. I did so and lost 20 kg, although I did less exercise. As you can see, I’m not overweight. What is more important is that I no longer have insulin resistance. But even more important, are these three questions that I have left and which do not want to be removed from me: How did this happen to me when I was thinking that I was doing everything right? If the science of healthy eating has been false, was it the same for others? And in analyzing these questions became almost obsessed in trying to understand the real connection between obesity and insulin resistance.
Now, many researchers believe that obesity is due to insulin resistance. Logically, when treating insulin resistance, it forces people to lose weight, right? Treats obesity. What if it is exactly the opposite? What if obesity is not the cause of insulin resistance? In fact, what if it were a symptom of a much bigger problem, the tip of an iceberg? I know that sounds a little strange, since we are in the middle of an obesity epidemic, but listen to me a little.
What if obesity is a camouflage of a much more serious problem that has roots in the cell? I’m not suggesting here that obesity is benign, but what I am suggesting is that it may be the lesser evil of the two evils of metabolism. You can think of insulin resistance as disability to distribute fuel, as I referred to a minute ago, to get the calories we provide with food and proportionately burn one part and preserve the other.
When we become insulin resistant, homeostasis in this type of balancing is disrupted. So now, when insulin tells the cell, I want to burn more energy than the cell considers it safe, it actually responds, “No thanks, I will save this energy.” And since we do not find them in fat cells those complex cellular machines found in other cells, is the best place to store it. Many of us, about 75 million Americans, insulin resistance response it may be to preserve it in the form of fat and not the other way around, having insulin resistance in response to obesity. This is actually a small change, but with severe consequences. Consider the following analogy: Think about the abrasions you experience on your skin when you accidentally slam your knee on the coffee table. Obviously the wound hurts a lot and you do not like the fact that it is smoky, but we all know that the wound itself is not the problem. In fact, it is the opposite, it is a healthy response to a trauma, are the immune cells that run where the damage occurred to help the cells there and stop the spread of the infection to other parts of the body.
Now, imagine if we thought the wound was actually the problem, and conduct any research and medical culture about wound treatment: masking creams, painkillers, and more, completely ignoring the fact that people are still slamming the cart on coffee tables. How much better it would be if we dealt with the causes– telling people to be more careful as you walk through the living room– instead of the effect that is created? Understanding cause and effect, makes all the difference possible. To be mistaken, the pharmaceutical industry may continue to be profitable for its investors but for people with cartilage killed nothing improves. Cause and effect. What I am suggesting is that perhaps we have the wrong cause and effect when faking for obesity and insulin resistance. Maybe we should ask ourselves, is it possible that insulin resistance causes weight gain and obesity-related diseases, at least in most people? What if being obese is simply a metabolic response to something much more threatening, a hidden epidemic, what should we worry about the most? Let’s take a look at the facts.
We know that 30 million obese Americans in the USA do not suffer from insulin resistance. And by the way, they do not seem to be us any greater risk for disease than weak people. Meanwhile, we know that 6 million people are weak in the USA are insulin resistant, and by the way, they are thought to be at greater risk for those metabolic diseases I mentioned above, in contrast to the obese group. I do not know why, but maybe it comes as a result of the fact that in their case, the cells have not yet figured it out what to do with the excess energy. So if a person may be obese and may not have insulin resistance, or it may be weak and have it, this indicates that obesity may be a camouflage for what is happening.
So what if we were fighting a wrong war, to fight obesity instead of insulin resistance? Even worse, it’s like blaming the obese does that mean we are blaming the victims? What if some of our core ideas on obesity are you wrong? Personally, I can not have it with the luxury of arrogance lets not talk then about the luxury of complete security. I have my ideas of what the problem might be, but I am open to suggestions. My hypothesis, because everyone asks me, this is.
If you are wondering, what is trying to protect the cell when it becomes insulin resistant, the answer is probably not, food surplus. But most likely, excess glucose: blood sugar. We know that processed cereals raises blood sugar levels in the short term, and there are also reasons to believe that sugar may lead directly to insulin resistance. If these psychological processes are put to work, casts the hypothesis that may be the cause of obtaining that processed grains, bulk sugar, what it brings epidemic of obesity and diabetes, but through insulin resistance, and not as an effect of overeating or not exercising. When I lost 20 kg a few years ago, I did it simply by limiting these things, which suggests I have a side based on my personal experience.
But that does not mean that my bias is wrong, and most importantly, all of these can be scientifically proven. But the first step is to accept the opportunity that our belief about obesity, diabetes and insulin resistance may be wrong and should therefore be tested. I bet my career on this. Today, I dedicate all my working time to this problem, and I will go everywhere to take science. I have decided that what I have I can not and will not do anymore is to pretend I have the answers when I do not have them.
I have been humbled by everything I do not know Last year, I was quite lucky that I worked on this problem with a wonderful group obesity and diabetes researchers in the country, and the most beautiful part is that, just as Abraham Lincoln surrounded himself with a rival working group, and we have done the same. We have recruited a working group with rival scientists, the best and the brightest, but they all have their own hypotheses about what may be at the heart of the epidemic. Some think it is the large amount of calories consumed. Others think that it is a great consumption of a fatty diet. For others, the problem lies in the consumption of cereals and starches.
But this working group of multi-disciplinary researchers, quite educated and quite talented, agree on two things. First, this problem is very important to continue to ignore it simply because we think we know the answers. And second, if we admit we are wrong, if we accept to challenge the knowledge so far with the best experiments offered by science, the problem can be solved. I know it’s pretty tempting to learn the answer right now, policies and measures, dietary recommendations– eat this, not that– but if we want to identify it exactly, we have to do a pretty rigorous science before we start giving recommendations. In short, to address this, our research program is focused around three main topics or questions. First, how do the different foods we consume affect in metabolism, hormones and enzymes, and through what molecular mechanism? Secondly, based on these data, can people make the necessary changes to their diet in a way that is safe and practical implementation? And finally, when we identify it what safe and practical changes people can make to their diet, how can we direct their behavior in that direction to become everyday and not the exception? Knowing what to do does not mean that you will always do it.
Sometimes it is necessary to put data around people to make it easier, and believe it or not, this can be studied scientifically. I do not know how this journey will end, but that seems clear to me at least: We can no longer blame the overweight and diabetic patients as bera une. Most of them actually want to make the right genes, but they need to know what that is, and should work. I dream of the day when our patients will be weakened and cure themselves of insulin resistance, as a medical professional, we have sweated our mental baggage and we have healed ourselves from resisting ideas enough to return to our ideals of origin: open mind, with courage to throw away yesterday’s ideas when they do not yield results, and understanding that scientific truth is not the last word, but in constant evolution.
Staying true to that path will be better for our patients and better for science, If obesity is nothing but camouflage of metabolic diseases, what good is it to us to punish those who suffer from it? It happens to me to think about the night in the emergency 7 years ago. I wish I could talk to that woman again. I would like to tell you how sorry I was. I would tell you that as a doctor, I gave it to her the best clinical service I could, but as human beings, I did not treat it properly.
You did not need my judgment. You needed my sympathy and pity, and above all you needed a doctor who would be willing to consider the fact that you could be outside the system. Maybe the system, of which I was a part, did not help you. If you are seeing this now, hope you can forgive me. (Applause).
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