Is the obesity crisis hiding a bigger problem Peter Attia
[Music]
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
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 get
fazt 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
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’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 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
scientific
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 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 a part was letting
you down if you’re watching this now I
hope you can forgive me
[Applause]
you