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