糖尿病与你的大脑

这会造成如此多的焦虑，我们根本不需要这样做。

It creates such anxiety, and we don't need to be doing that.

如果你真的担心血糖水平，可以买个血糖仪，测几次看看情况。

If you're really concerned about your blood glucose levels, could get a glucometer, test it a few times, see where you're at.

但我认为这真的有些过头了。

But I think it's really going overboard.

至于血糖的波动起伏，我们的身体其实是精妙绝伦的机器。

And then in terms of blood glucose and the ups and downs and all of that, our bodies are really amazing machines.

我们的身体天生就能摄入食物，并将食物中的营养和能量吸收进血液。

And our bodies are designed to take in food, and that food, the nutrients and energy from the food, get absorbed into the bloodstream.

然后我们就能将这些能量输送到所有需要能量的细胞。

And then we're able to send it to all the cells that need energy for whatever reason.

当然，当我们进食时，血糖自然会升高。

And of course, when we eat, our blood sugar is going to go up.

它必须升高，因为我们需要为细胞提供能量。

It needs to go up because we need to be getting energy to those cells.

当能量被消耗后，血糖自然会降下来。

And then once the energy gets used, of course, it's going to come down.

确实如此。

And, yes, it's true.

我们不应该采用会导致血糖剧烈波动的饮食方式。

We don't want to be eating a diet that causes these huge spikes and sudden drops.

比如摄入大量精加工食品和含糖饮料这类情况。

So this would be where you're eating really highly refined foods and drinking a lot of sugar sweetened beverages and things like that.

我们真正需要的是血糖平缓升降，这可以通过食用富含纤维的食物来实现，因为纤维能延缓食物吸收，使血糖缓慢平稳下降。

But we do want a gradual rise and then a gradual fall, but that we get when we consume foods that contain fiber, that slow the absorption of the foods and allow for a gentle, slow reduction.

目标不是让血糖保持直线。

The goal isn't to flat line our blood sugar.

葡萄糖确实是人体最重要的能量形式。

Glucose is really the most important form of energy for the body.

所以我认为我们需要更全面地看待这个问题，认识到人体具有处理碳水化合物的惊人能力，也具有强大的自我修复能力。

So I think we really need to be more balanced with all of that and recognize that the body has an amazing capacity to handle carbohydrates, and it has an amazing capacity to heal itself.

只要我们提供全食物，尤其是富含所有这些对人体健康具有保护作用的化合物的全植物性食物，身体就会自然而然地做到这一点。

And it will do that if we provide it with whole foods, particularly whole plant foods that are really concentrated in all of these compounds that are so protective to human health.

确实如此。

That's true.

你说得太美妙了。

You say it so beautifully.

这其中有一个我们不容忽视的更宏大的议题。

There is a bigger conversation there that we cannot ignore.

这必须成为我们决定餐盘内容的一部分——是什么造就了健康的身心，是什么促使我们做出更健康的选择。本次对话的目标正是如此：让我们面前的食物和营养既有利于自身健康，也有益于大脑心智，乃至整个世界。

It has to be a part of this decision of what we put on our plates, of what makes a healthy person a healthy mind that makes healthier decisions the goal of this conversation was just that to make our food and the nutrients that we put in front of us healthy for ourselves, for our brain and mind and the rest of the world as well.

非常感谢你这番话。

So thank you for saying that.

这一点极其重要。

That's incredibly important.

既然提到大脑，因为这才是这一切的核心所在。

Then mentioning the brain, because that's what this is all about.

2型糖尿病。

Type two diabetes.

是的，这是一个血糖问题。

Yes, it's a blood glucose problem.

是的，这是一个脂毒性问题，但它实际上是一种全身性疾病。

Yes, it's a lipotoxicity problem, but it's really a whole body disease.

它会影响你的血管。

It affects your blood vessels.

它会影响你的心脏、眼睛和肾脏。

It affects your heart, your eyes, your kidneys.

但当然，毫不意外的是，它也会影响你的大脑，这是最易受损的靶器官之一。

But of course, not surprisingly, it also affects your brain, which is one of the most vulnerable targets of all.

2型糖尿病患者出现认知功能下降的风险要高得多。

People with type two diabetes are much more likely to experience cognitive decline.

这并非巧合，而是真正的生物学机制。

And it's not just a coincidence, it's really biology.

要知道，胰岛素抵抗不仅发生在身体其他部位，同样也会发生在大脑中。

You know, insulin resistance happens in the brain as it happens everywhere else.

它会减缓大脑的运作速度。

It slows things down.

导致我们的记忆衰退，大脑变得更加脆弱。

It causes our memories to falter and our brains to become more vulnerable.

高血糖会引发氧化应激和炎症，产生诸如晚期糖基化终末产物等有毒副产物，这些物质会损伤血管，并在大脑中加速斑块的形成和堆积。

High blood sugar leads to oxidative stress and inflammation, creates toxic byproducts like advanced glycation end products, which damage blood vessels and accumulate and accelerate plaques in the brain.

此外，糖尿病当然还会影响大脑的血液供应，减少血液循环并导致血管狭窄。

And then you've got diabetes affecting, of course, the brain's blood supply, reducing circulation and narrowing of the blood vessels.

胰岛素在清除β淀粉样蛋白（阿尔茨海默病中堆积的蛋白质）方面也起着重要作用。

Insulin also plays a role in clearing out amyloid beta, the protein that builds up in Alzheimer's.

所有这些因素共同作用，将我们置于危险之中。

All of these things come together to put us at peril.

因此我们必须明确认识到，二型糖尿病会让我们面临更高的认知疾病风险。

And so we need to recognize definitely type two diabetes is putting us at much greater risk for these dreaded cognitive diseases.

同意。

Agreed.

现在我们进一步了解到它如何影响帕金森病和其他神经退行性疾病。

And now we're learning more about how it impacts Parkinson's disease and other neurodegenerative diseases as well.

正如你所说，这是一种全身性疾病。

So like you said, it is a whole body disease.

饱和脂肪在二型糖尿病发展中扮演什么角色？

How does saturated fat play a role in the development of type two diabetes?

要知道，确实有几种特别有害的脂肪类型。

You know, there are really a couple of different types of fats that are especially problematic.

一种是饱和脂肪，另一种是反式脂肪酸。

One is saturated fat and the other is trans fatty acids.

第三种我称之为氧化脂肪。

And a third is what I would label as oxidized fats.

就是那些因受热、光照或氧化等因素而变质的脂肪。

So fats that have been damaged by heat, light, oxygen, whatever.

而不饱和脂肪则恰恰相反，它们往往会对胰岛素敏感性产生负面影响，而不饱和脂肪则倾向于改善胰岛素敏感性。

And unsaturated fats, on the other hand, tend to have a negative impact on insulin sensitivity, whereas unsaturated fats tend to improve insulin sensitivity.

完全正确。

Absolutely.

如果有人想要做出一些改变，但他们还没准备好或目前没有条件完全转向以植物为主的饮食，那我们来谈谈那些实际患有二型糖尿病的人群。

If someone wants to make some changes and they're not ready or they don't have the resources to go plant based or fully plant predominant at this point, let's talk about specific people who are actually experiencing type two diabetes.

他们今天可以对自己的饮食模式做出哪些最简单且最重要的改变，以感觉更好并更好地控制他们的二型糖尿病？

What would be the easiest and the most important changes that they could make today to their dietary pattern to feel better and get a better handle on their type two diabetes?

显然，我们建议他们与医生合作，并尽可能与当地的注册营养师合作，但就饮食改变而言，一般建议是什么？

Obviously, we suggest that they work with their physicians and they work with a registered dietitian in their area if they can, but what would be the general recommendation as far as dietary changes are concerned?

我要说的第一点是增加蔬菜摄入量，尤其是非淀粉类蔬菜，如绿叶蔬菜，以及像浆果这样营养密集的水果，还有我们所说的十字花科蔬菜，如西兰花和羽衣甘蓝等。

I would say number one, increase your intake vegetables and especially non starchy vegetables like leafy greens and then fruits like berries and things that are really nutrient dense, what we call cruciferous vegetables like broccoli and things like that, kale.

第二点是尝试增加豆类的摄入。

Number two is to try to add in legumes.

即使只是一份扁豆汤或撒在沙拉上的罐装豆子，你不需要做到完美。

If you could have one serving, even if it's a, you know, a lentil soup or some beans from a can sprinkled on a salad, you don't have to be perfect.

但可以加入一些豆类，比如毛豆或豆腐。

But adding in some legumes, it could be edamame, it could be tofu.

不过一般来说，整粒豆类绝对是首选，因为富含纤维。

But generally, whole beans are absolutely preferred just because of the fiber.

当你刚开始转变饮食习惯时，确实需要最大化纤维摄入。

And when you're just starting to do the transition, you really want to maximize that.

你已经增加了水果和蔬菜的摄入。

You've added in fruits and vegetables.

你已经增加了豆类的摄入。

You've added in legumes.

你还可以增加全谷物的摄入。

You can add in whole grains.

说到全谷物，其实是用全谷物替代精制谷物。

And when whole grains, you're really swapping out refined grains for whole grains.

但人们必须认识到并非所有全谷物都一样，因为即使是全谷物也会经历不同程度的食品加工，其益处很大程度上取决于加工程度。

But people have to recognize that all whole grains aren't equal, because even whole grains are exposed to different levels of food processing, and their benefits are really dependent on how much they're processed.

所以如果你吃的是全谷物，比如全麦大麦或藜麦，对健康的影响将远大于食用由全谷物制成的加工食品，如全麦面包或全麦谷物。

So if you're eating a whole grain, like, some whole barley or quinoa, the impact on your health will be far greater than if you're eating a processed food made from whole grains, whole grain bread, or whole grain cereal.

因此你希望摄入一些加工程度较低的全谷物。

So you're wanting to incorporate a little bit of less processed whole grains.

你希望这些食物能逐渐取代那些更有害的食物。

And so what you want to happen is you want those foods to start crowding out the foods that are more damaging.

你可以从早餐开始，把加工早餐麦片换成钢切燕麦或燕麦粒之类的食物。

So you can start with breakfast and swap out your processed breakfast cereal for steel cut oats or oat groats or something like that.

你可以用一块豆腐或一些豆类来替代部分鸡肉或牛肉。

You might be able to swap out some chicken or beef with piece of tofu or some beans.

或者不吃牛肉卷饼，改吃豆子卷饼之类的。

Or instead of a beef burrito, you have a bean burrito or something like that.

做出这些改变时，不必一次性完成。

And then making the change, it doesn't have to be all at once.

你可以先从早餐开始，然后是午餐，再到晚餐。

You might wanna start with breakfast and then go to lunch and then go to dinner.

首先，增加那些健康的植物性食物，用它们替代部分动物性食物。

But so number one, adding in those healthy plant foods, swapping them out for some of the animal foods.

其次，要真正审视你的饮食，看看自己实际摄入了多少超加工食品，以及如何替换它们。

And then the other thing is to really examine your diet in terms of how much ultra processed food am I actually consuming, and how could I switch that.

例如，如果你在喝含糖饮料，可以换成无热量的调味气泡水，比如不含添加糖的橙味气泡水。

So if you're drinking sugar sweetened beverages, for example, you might switch that for a non caloric, just flavored soda water, like an orange soda water that doesn't have any added sugar.

或者更好的是，直接用普通气泡水加几片橙子或几颗草莓，既美观又美味。

Or better still, just a plain soda water with a few slices of orange or a couple of strawberries to make it look nice and taste good.

这类替换方式还有很多，比如把零食从薯片换成坚果和水果之类的组合。

So there those kinds of swaps, you can swap out if you're eating snack foods to swap from having potato chips to having something like some nuts and a piece of fruit, for example.

总之有各种方法可以帮助你从吃袋装盒装食品转向真正完整的天然食物。

So there are all kinds of ways you just wanna move from eating foods in boxes and bags to eating foods that are really, truly whole foods.

太棒了，非常感谢。

Beautiful, thank you so much.

这些建议真的非常实用。

That was actually very helpful.

这类问题是我们每天为患者解答的日常问题。

These are the kind of questions that we have to answer on a day to day basis for our patients.

所以我非常喜欢‘增加而非否定和去除’的理念。

And so I love the concept of adding things instead of negating and removing things.

这让改变更友好、更可行。我们都知道，剥夺式节食绝不是开启健康之旅的最佳方式。我们经常讨论营养问题，你曾与不同社区合作过——从文化适配的营养干预措施中我们能学到什么？其实大多数这类建议听起来都像宣传册上的套话，比如‘要这样做’。就像我们看到地中海饮食模式时，人们总以为必须完全照搬地中海地区的烹饪方式。实际上每种饮食模式都可以调整得既符合健康需求又...我希望你能谈谈饮食文化和实际考量。

So it makes it friendlier it makes it doable and you and I both know that deprivation is not the best beginning for going towards your health journey and I know that we talk a lot about nutrition and you've worked with different communities what can we learn from, culturally tailored nutritional interventions you know so most of this information seems like it's almost a brochure thing to say like do this or for example even when we look at dietary patterns like the Mediterranean diet people think that they have to start eating like how Mediterranean regions cook their food every dietary pattern can be tailored in a way that is good for health as well I wanted you to touch on the cultural and the practical considerations of diet.

是的。

Yeah.

我认为关键在于，任何饮食转变都必须尊重文化相关性。

I just think it's really critical when we're making a transition that it be the kind of transition that respects making the transition culturally relevant.

否则就不会奏效。

Because if it's not, it won't work.

人们无法长期坚持。

People won't stick to it.

我们需要保持文化谦逊。

And we need to have some cultural humility.

我们需要合作。

We need to collaborate.

如果我们服务的群体与我们的文化背景不同，就需要让他们在决定什么方案最适合自己时拥有最大的话语权。

If we're working with a population who has some cultural differences from what we're used to, we need to help to make them the ones that have the greatest say in what will work for them.

我记得马绍尔群岛的例子。

I can remember the Marshall Islands.

我们与马绍尔群岛居民密切合作，他们教会我们了解他们喜爱的食物和当地食材，这样我们就能在保留这些食谱精髓的同时，让它们变得更健康，从而更容易被当地民众接受。

We worked very closely with Marshallese people who could teach us about the foods that they enjoy, the foods that they have access to, so that we could help them keep the essence of those recipes, but making them a little healthier so that they would be more embraced or easily embraced by the population.

我在马绍尔群岛发现，如果某个想法源自当地人，就总能获得很好的接受度。

And I found in the Marshall Islands, if the idea came from a Marshallese person, it just always worked so well in terms of acceptance.

因此我们竭尽全力尊重他们的想法，而他们也提出了许多绝妙的建议。

And so we really tried our best to honor their ideas, and they came up with wonderful ideas.

总的来说，我认为最关键的是要与目标群体紧密合作，尽可能让他们担任领导角色。

So generally, I think it's just so important to work closely with whatever population you're trying to impact and put them in leadership capacities as much as possible.

布伦达真是太棒了。

Brenda's amazing.

每次与她交谈，我们都能从她身上学到很多。

Whenever we speak with her, we learn so much from her.

她分享了一种非常细致且平衡的糖尿病治疗方法。

And she shares a very nuanced and balanced approach to diabetes.

我很欣赏她理解健康社会决定因素的重要性，她毕生的工作堪称典范。

And I love that she understands the importance of social determinants of health, and her life's work is exemplary.

她是一位了不起的人，不仅从事科学研究，还将成果转化到社区实践中。

She's an incredible human being that doesn't just do the science and the research, but also translates it in communities.

事实上，她之所以闻名世界，部分原因正是她在群岛的工作。

In fact, one of the reasons she became world renowned was her work in the islands.

马绍尔群岛。

Marshall Islands.

马绍尔群岛的工作只是整个营养、糖尿病与生活方式变革运动的开端。

Marshall Islands, which was just the beginning of an entire movement of nutrition and diabetes and lifestyle.

能有她这样的朋友，我们感到无比自豪。

So we are so proud to have her as a friend.

确实如此。

Absolutely.

我们的下一位嘉宾将讨论如何在临床环境中以同理心和周全考虑引入这些营养理念。

Our next guest discusses the how of introducing these nutrition concepts in clinical settings with compassion and consideration.

医生。

Doctor.

米歇尔·麦克马肯，我亲爱的朋友，是纽约市健康与医院系统营养与生活方式医学的执行主任，这是美国最大的公共卫生医疗系统。

Michelle McMacken, my dear friend, is the Executive Director of Nutrition and Lifestyle Medicine at NYC Health and Hospitals, the largest public health care system in The United States.

作为贝尔维尤医院的内科医生和纽约大学格罗斯曼医学院的副教授，她创立了开创性的贝尔维尤生活方式医学项目，旨在改善高风险社区的心血管代谢健康。

An internist at Bellevue Hospital and Associate Professor at NYU Grossman School of Medicine, she founded the pioneering Bellevue Lifestyle Medicine program to improve cardiometabolic health in high risk communities.

在她的领导下，该项目已扩展到纽约市七个地点，将生活方式改变与社会支持相结合。

Under her leadership, the program has expanded to seven sites across NYC integrating lifestyle change with social support.

她曾三次荣获年度教师奖。

She's a triple time teacher of the year awardee.

医生。

Doctor.

麦克马肯拥有耶鲁大学的学位，并获得内科和生活方式医学委员会认证。

McMacken is board certified in internal and lifestyle medicine with degrees from Yale.

她是个摇滚明星，以下是我们的对话。

She's a rock star and here's our conversation.

米歇尔，非常感谢你抽空参加。

Michelle, thank you so much for your time.

我非常感激能和我在地球上最喜欢的人之一，谈论我们都非常热衷的话题——患者护理以及为他们提供自我护理的资源。

I am so grateful that I get to talk to one of my favorite people on planet earth about something that we're both very passionate about which is patient care and also giving them resources to take care of themselves.

非常感谢你抽空参加。

Thank you so much for your time.

谢谢你的邀请。

Thank you for inviting me.

我也同样感谢你。

And it's right back at you.

能来到这里我深感荣幸，对你所做的一切我感到无比自豪。

I'm extremely honored to be here, I'm just so proud of everything that you're doing.

所以这是相互的。

So it's very mutual.

你真是太好了。

That's very kind of you.

谢谢。

Thank you.

那么，我们今天要讨论的是糖尿病。

So, we're talking about diabetes today.

米歇尔，我们的观众主要是那些在健康与 wellness 的海洋中遨游的可爱人群。

And Michelle, our audience is composed mostly of lovely people who are kind of just swimming through this ocean of health and wellness.

你也知道社交媒体上会有多疯狂。

And you know how crazy it can get on social media.

有时你会看到定义在变，观点在变。

And sometimes you see definitions changing, perspectives changing.

我觉得人们在这个领域里越来越难以驾驭和导航，尽管我们已经有足够的信息来帮助我们制定管理风险因素的指南，特别是糖尿病。

I feel like it's becoming really difficult for people to maneuver and navigate through this field, despite the fact that we have enough information to help us create a guideline to manage our risk factors, specifically diabetes.

我想通过向大家描述什么是糖尿病以及它对我们的身体有何影响来开始这次对话。

And I would love to start this conversation by just giving you the feel to describe what diabetes is and what is it doing to our bodies.

我认为这是个很好的切入点。

I think that's a great place to start.

我觉得应该尽量简化说明，显然我们主要会关注二型糖尿病。

I think that just keeping it very simple, obviously, I think we're going to be focusing primarily on type two diabetes.

当然，糖尿病有不同的类型。

Of course, there are different types.

所以我将重点讨论二型糖尿病。

So I'll focus on type two.

实际上，当你的组织对胰岛素的反应不如预期时，就会出现血糖调节问题。

Really what happens is when your tissues are not responding as well as they should to insulin, you have problems regulating your blood sugar.

这背后其实是一个影响多个器官的复杂过程。

There's really a whole underlying process that's affecting multiple organs.

血糖问题只是冰山一角，我想我们稍后可能会深入探讨这个问题。

The sugar is just the tip of the iceberg, and I think we may get into that.

但基本上，这就是核心理念。

But really, that's the basic idea.

二型糖尿病确实具有家族遗传倾向。

Type two diabetes is something that can definitely run-in families.

我发现很多患者来找我时，都担心自己会患上二型糖尿病，因为他们的家族中有多位成员患有此病。

And I think a lot of my patients come to me concerned that they may develop type two diabetes because it runs in so many family members.

能够告诉人们其实有很多方法可以降低二型糖尿病风险，这实在是莫大的荣幸。

And it's actually an extraordinary privilege to be in the position to tell them that there's a lot that people can do to lower the risk of type two diabetes.

太棒了。

Amazing.

是啊。

Yeah.

说到预防措施，与二型糖尿病密切相关的概念之一就是糖或碳水化合物。

Speaking about things they can do, one of the concepts that is adjacent to type two diabetes is sugar or carbs.

当观察社会上的普遍讨论时，人们常简单粗暴地认为糖有害、碳水有害，只要戒掉碳水糖尿病就会好转。但证据表明实际情况要复杂得多，能否请您谈谈这一点？

And when you look at the conversation that is out there in the ether, the simplistic way of describing that is sugar is bad carbs are bad get rid of carbs and your diabetes is going to get better but when you look at the evidence it's much more nuanced than that can you touch on that please

是的，我数不清有多少次与人们进行一对一交流，或是与医疗从业者和公众讨论这个话题。

yeah I can't tell you how many times I've had this conversation one on one with people and in talks with medical providers, with the public.

关于健康碳水化合物食物、碳水化合物整体及其对血糖的影响，存在着普遍误解。

There is such a pervasive misunderstanding about healthy carbohydrate foods, carbohydrates in general, how they affect blood sugar.

我喜欢这样思考：当你观察富含碳水化合物的食物时，首先我尽量避免在诊疗中使用'碳水'这个词，因为很多人对这个概念感到困惑。

The way I like to think about it is that when you look at, say, for example, carbohydrate rich foods, first of all, the term carbs, I try not to use that word in my practice because a lot of people get confused as to what that means.

富含碳水化合物的食物可以是从扁豆到棒棒糖的任何东西。

A carbohydrate rich food could be anything from lentils to lollipops.

它们对我们身体的健康影响截然不同。

Those are very different health effects in our body.

所以我尽量完全不使用'碳水'这个术语。

So I try to stay away from using the term carbs at all.

只讨论那些更有营养的食物，或是我们需要限制或避免的食物。

Just talk about the actual foods that are more nutritious or that we want to limit or avoid.

不过假设我们现在讨论的就是碳水化合物。

But let's say we're talking about carbohydrates.

我们知道，当我们摄入含碳水化合物的食物时，血糖会升高。

We know that when we eat food that contains carbohydrates, our blood sugar will rise.

这就是第一个误解产生的地方。

And that's where the first misunderstanding comes in.

很多人认为我的血糖根本不应该有任何波动。

A lot of people think my blood sugar shouldn't be changing at all.

而我总是解释说，餐后血糖升高是完全正常的现象，尤其是吃了含碳水化合物的餐食后。

And I always explain it is completely normal for your blood sugar to rise after you eat a meal, especially a meal that contains carbohydrates.

问题在于当血糖升高到不恰当的高水平时。

The problem comes in when the blood sugar rises inappropriately high.

这主要是由胰岛素抵抗引起的。

That is driven by resistance to insulin.

稍微展开解释一下，如果我们更深入观察，正常情况下（即没有胰岛素抵抗的人），当你吃含碳水化合物的食物时——比如你饿了吃根香蕉。

So to unpack that a little bit, if we just look a little bit deeper, what's going on is that in the normal state, so someone is not living with insulin resistance, when you eat a food that contains carbohydrate, let's say you eat a banana, you're hungry, you eat a banana.

这时你的血糖开始上升，血糖升高会触发胰腺释放胰岛素。

What happens is your blood sugar starts to rise, your blood glucose starts to rise, that triggers the release of insulin from your pancreas.

胰岛素随后会到达我们的肌肉细胞，帮助血液中的葡萄糖进入这些肌肉细胞。

Insulin then travels to our muscle cells and it helps the glucose in our blood enter those muscle cells.

这非常棒，因为我们可以利用葡萄糖，将肌肉中的能量用于我们需要做的事情，或者将其安全地储存为糖原。

That's wonderful because we can use the glucose, the energy in our muscles for the things that we need to do, or we can store it safely as glycogen.

这就是正常的生理过程。

So that's the normal process.

当我们出现胰岛素抵抗时会发生什么呢？我们吃下同样的香蕉，血糖开始上升，触发胰岛素释放。

What happens when we have insulin resistance is that we eat that same banana, our blood sugar starts to rise, triggers the release of insulin.

胰岛素试图帮助肌肉细胞吸收葡萄糖，但由于某些原因受阻了。

Insulin tries to help the muscle cell absorb that glucose, but for some reason it's blocked.

如果你是患有二型糖尿病的人，刚吃完那根香蕉后检测血糖，会发现血糖升高了，于是担心自己不该吃香蕉，因为血糖升得这么高。

And if you're that person who's living, say, with type two diabetes and you've just eaten that banana and you check your blood sugar, you're going see your blood sugar's gone up and you're going to worry that maybe I shouldn't be eating bananas because look how high my blood sugar went.

但你必须自问：血糖升高真的是香蕉的错吗？还是肌肉细胞内部的问题？

But you have to ask yourself, is that rise in the blood sugar actually the banana's fault Or is it the fault of something that's going on inside the cell itself of the muscle?

而我们已知的是，导致这个根本过程的原因——为什么胰岛素无法帮助肌肉细胞吸收葡萄糖——与肌肉中特定类型脂肪的积累有关。

And what we do know is that what's driving that underlying process, why insulin is not able to help the muscle cell, for example, absorb glucose has to do with the buildup of specific types of fats inside the muscle.

这实际上是由一系列复杂因素共同作用导致的，包括炎症反应、长期摄入过多热量、身体活动不足等多种原因，而这些因素又往往会引起更多炎症。

That is in turn due to a complicated symphony of things, including inflammation, consuming too many calories day in and day out, not moving your body enough, a variety of different things, inflammation that results from a lot of these things.

因此单纯关注血糖升高未必能抓住问题的本质。

And so just to look at the rise in blood sugar is not necessarily the problem.

问题的根源要深刻得多，我们需要从更深层次来解决。

The problem is much deeper than that, and we can address that at a deeper level.

嗯。

Yeah.

我很高兴你提到了这点。

I'm so glad you, touched on that.

非常感谢。

Thank you so much.

最让我抓狂的是看到Instagram上那些卡通化的血糖升降图——那些毫无缘由的小波动被渲染成危险信号。

One of the things that drives me nuts, especially looking at some Instagram posts of cartoonish representation of glucose going up and then down, And basically, for no rhyme or reason, that little spike is actually termed as something dangerous.

这本质上是在把正常生理现象病理化。

It's essentially pathologizing normal physiology.

就像你说的，血糖那样上升是非常正常的，但每个人都想让它保持平稳。

Like you said, it's very normal for your glucose to go up like that and everybody wants to flatline it.

而且还有人推荐一些奇怪的方法。

And there are these strange techniques that are recommended.

比如，如果你在吃这个之前先吃那个，你的血糖就不会升高。

Oh, if you eat this before this, your blood glucose is not going to rise.

我理解你想确保自己没有异常的血糖峰值，而且有非常具体的数值定义。

I do understand that you want to make sure that you know you don't have an abnormal spike and there are very specific numbers that define it.

不仅仅是看一张没有任何数字的图表——通常那些图表上确实没有数字。

It's not just looking at a diagram without any numbers on it, which usually there is no numbers on those diagrams.

现在人们戴着时髦的连续血糖监测仪，炫耀说'哦，我非常清楚自己的血糖波动情况'。

Now people are wearing like sexy CGMs to say like, Oh, I have a really good understanding of how my glucose is going up and down.

但实际上这毫无意义。

But in reality, it doesn't mean anything.

特别是对没有糖尿病或胰岛素抵抗问题的人来说，这完全没用。

And especially if someone doesn't have diabetes or if someone is not experiencing insulin resistance, it's of no use.

所以我非常主张，如果你没有那些医疗状况，就不必佩戴连续血糖监测仪。

So I'm a big proponent of saying you don't have to wear CGM if you don't have those medical conditions.

对此你有什么看法？

What are your thoughts on that?

哦，是的，我认为连续血糖监测仪在特定情况下确实有其作用。

Oh yeah, no, I think there's definitely a role for CGMs in very specific situations.

但如果你没有二型糖尿病，使用连续血糖监测仪并没有明确的益处。

But if you don't have type two diabetes, there is no established benefit to using a CGM.

即便是对于二型糖尿病患者，也需要稍加谨慎，因为如果你仅仅关注进食特定食物或餐食后的血糖变化，有时会让人误以为他们因摄入低碳水化合物食物而受到奖励，进而认为'我正在通过避免所有碳水化合物来解决问题'。

Even in people who do have type two diabetes, you have to be a little bit careful because what happens is if you're just looking purely at the change in blood sugar after you eat a specific food or meal, sometimes it can reward people, think that they're rewarded for consuming foods that are low in carbohydrates and just thinking, well, I'm fixing the problem because I'm avoiding all carbohydrates.

而实际上，某些不含碳水化合物的食物——比如你正在吃加工肉类制成的餐食——

When in reality, some of those foods that don't contain carbohydrates, for example, let's say you're eating, you know, you're eating a meal that contains processed meats.

假设你正在享用培根鸡蛋奶酪三明治，

Let's say you're feasting on bacon, egg and cheese.

这种食物不会使你的血糖大幅上升，因为它不含大量碳水化合物。

That is something that is not going to drive your blood sugar up very much because it doesn't contain a lot of carbohydrates.

但它会加剧胰岛素抵抗这一潜在过程。

But what it is going to do is drive the underlying process of insulin resistance.

它会促进更多脂肪的堆积，我们称之为脂毒性，不仅存在于肌肉细胞中，还会导致肝脏功能障碍和脂肪组织异常。

It's going to drive more of that buildup of fats, what we call lipotoxicity, not just in our muscle cells, but also in our liver dysfunction of the adipose tissue, the fat tissue.

它会推动所有导致二型糖尿病的病理进程。

It's going to drive all of those processes that define type two diabetes.

因此，当你食用健康、营养丰富且富含碳水化合物的食物（如传统燕麦片或香蕉）时，与你日常不摄入这些食物的情况相比，血糖会出现更高的峰值。

And therefore, you go to consume a healthy, nutritious, carbohydrate rich food, such as old fashioned oatmeal or a banana, you're going to see a higher spike in glucose than if you were not including those foods regularly in your diet.

确实如此。

Absolutely.

所以我想强调你刚才说的这一点，这非常重要。

So I want to emphasize what you just said, which is very important.

所以我是在重复你的观点。

So I am repeating what you're saying.

除了血糖异常之外，还有其他代谢途径和其他通路实际上也可能导致二型糖尿病。

Beyond just glucose abnormalities, there are other metabolic and there are other pathways that can actually contribute to type two diabetes.

所以人们需要意识到这一点。

So people need to be aware of that.

例如，如果他们胆固醇过高或存在其他影响身体细胞的问题，这些问题甚至可能增加他们患糖尿病及其并发症的风险。

So for example, if they have high cholesterol or if they have some other issues that are affecting the cells in their body that could maybe even potentiate the chances of them having diabetes and its manifestations.

是这样吗？

Is that correct?

是的，这是一个涉及多个不同器官的复杂过程。

Yes, it's a complex process that involves multiple different organs.

虽然长期高血糖本身会加剧疾病进程，但它最初并非主要问题。

Although high glucose itself, chronic, very elevated glucose can contribute to the underlying disease process, it is not originally the primary problem.

这更像是潜在功能紊乱的症状，与炎症、肌肉组织中脂肪堆积有关——这些脂肪堆积是炎症、细胞压力以及其他随时间发展的问题导致的，通常发生在具有遗传易感性的人群中，且往往由生活方式因素推动。

It's more of a symptom of the underlying dysfunction that's going on that's related to inflammation, the buildup of these fats in different muscle tissues that are the result of inflammation, cellular stress, and other things that come about over time, typically in a person who's genetically susceptible and in many cases driven by lifestyle factors and contribution.

太精彩了。

Amazing.

我们刚才稍微提到了胰岛素抵抗。

We've touched on insulin resistance a little bit.

简单来说，这个概念指的是你体内的细胞无法正常利用胰岛素。

So basically it's a concept where the insulin is not used properly by the cells in your body.

作为一名临床医生，面对前来就诊并担心患有胰岛素抵抗的患者，我们医生会采取哪些措施来应对？

As a clinician, as someone who sees patients, if someone comes in and they're concerned about having insulin resistance, what are some of the things that we do as a physician to address it?

这到底意味着什么？

And what does that even mean?

对此你会怎么做？

What do you do about it?

是的，当患者向我表达对家族中有二型糖尿病史的担忧，或者我们通过筛查血液检测发现他们的平均血糖（即糖化血红蛋白A1C）处于临界范围时——

Yeah, mean, I think that when I hear from my patients that they have a concern about a family history of type two diabetes, or we've done screening blood tests, and I've seen that their average blood sugar called the A1C is in the borderline range.

我就知道他们未来有发展成显性二型糖尿病的风险。

And I know that they are therefore at risk of developing overt type two diabetes in the future.

这种时候正是采取干预措施的黄金窗口期。

That's a situation where this is really a prime opportunity to act.

在这个阶段，我和其他临床医生可以通过多种不同方式来帮助患者。

And there's so many different ways that I and other clinicians can support patients in this moment.

我认为首要的是让人们明白，他们可以采取许多措施来大幅降低患2型糖尿病的风险。

I think the first thing is for people to understand that there are a lot of things that they can do to dramatically lower the risk of developing type two diabetes.

人们可以在生活方式上做出这些改变，而当他们有一个团队支持时，这些改变效果最佳。

And those changes that people can make around their lifestyle really work best when they're supported by a team.

因此，我发现很重要的一步是告诉我的患者：你能做的有很多。

So I have found it's an important step for me to tell my patients there's a lot you can do.

这些是你可着手改进的方面，但更重要的是我要坐下来了解：这个人的目标是什么？

These are some of the categories of things that you can work on, but it's so much more important that I sit down and understand what is the person's goal?

他们来自怎样的背景？

Where are they coming from?

他们认为哪些因素会阻碍目标实现？这样我才能真正解决这些问题。

And what are the things that they think are going to make that hard so that I can actually address those things?

营养是这个等式中至关重要的一环。

Nutrition is a huge part of this equation.

而且我很喜欢讨论食物。

And I love to talk about food.

我热爱讨论营养学。

I love to talk about nutrition.

如果我能和每位患者单独在房间里聊上两小时这个话题，我会的。

If I could just sit in a room with my patients for two hours each and talk about that, I would.

但有时我会发现，比如有人睡眠不足。

But sometimes I find out, for example, that someone is not sleeping.

他们睡眠质量很差。

They're not sleeping well.

实际上我必须从这个问题着手。

I actually have to start there.

我们都关注饮食和运动，但如果某人承受巨大压力或睡眠不足，这会极大影响他们改变饮食和运动习惯的能力，同时还会独立加剧炎症和二型糖尿病的发展进程。

We all think about diet and exercise, but if someone's facing a huge amount of stress or they're not sleeping, that can actually dramatically affect their ability to make changes in terms of diet and exercise and plus independently contribute to the inflammation and the disease process in type two diabetes.

因此这实际上是一个需要协调的过程：既要考虑我们对二型糖尿病发展的认知，又要结合已知的有效措施，同时兼顾患者的生活现状，找出当下最适合的帮助方式。

So it's really a process that involves this dance between what we understand about the development of type two diabetes, what we know can help and what the patient's life circumstances are, and how can we best help them in that moment.

我们确实能做的工作还有很多很多。

And there's really, there's so much that we can do.

我们将深入探讨如何根据人们的现状来帮助他们，以及他们短期内可以采取的措施。

We'll take a deep dive on that, how to meet people where they are and what they can do in a few moments.

您一直是饮食营养与糖尿病及其他老年慢性疾病管理，特别是糖尿病方面的有力倡导者。

You've been a powerful advocate of diet and nutrition and management of diabetes and other chronic diseases of aging, but specifically diabetes.

您对此有过著述和发表，我很希望您能先概述饮食如何普遍影响胰岛素敏感性，同时您也提倡植物性营养在医学中的应用。请为我们简要介绍目前关于饮食对糖尿病影响的认知。

And you've written about it, you've published about it and I would love for you to start describing how diet in general impacts insulin sensitivity and also you've been a proponent of a plant based nutrition in medicine as well So give us a synopsis of what we know about the impact of diet on diabetes.

饮食是预防、治疗甚至可能逆转二型糖尿病极其重要的一环。

Diet is an incredibly important part of the prevention and treatment and even potential for remission of type two diabetes.

我们可以稍作展开，但已知食物中的不同成分、不同元素以及我们的整体饮食模式，尤其是像膳食纤维这样的营养素，发挥着巨大作用。

We can unpack that a little bit, but we know that the different components, the different elements of the foods that we eat and our overall eating patterns, particularly nutrients like fiber, play an enormous role.

我想重点谈谈膳食纤维，因为根据定义，纤维只存在于植物源性食品中。

I wanna touch on fiber because fiber, of course, is only found in foods that come from plants by definition.

而这种营养素正是许多美国居民摄入不足的。

And it's a nutrient that many people living in The United States are not eating enough of.

我们的摄入量远未达到推荐标准。

We're not really anywhere near the recommended amount.

膳食纤维能发挥多种作用。

What fiber can do is a few different things.

第一，它能减缓餐后血糖的上升速度。

Number one, it blunts that rise in blood sugar when we're eating a meal.

所以如果你摄入的是富含纤维的碳水化合物食物，血糖上升就会变得平缓。

So if you're consuming a carbohydrate rich food that contains more fiber, that rise in blood sugar will be blunted.

这是个很好的开端。

So that's a great first step.

但更重要的是，纤维实际上降低了许多食物的热量密度。

But more importantly, fiber actually lowers the calorie density of a lot of the foods that we're consuming.

这确实有很多好处。

And that's actually really wonderful for a number of different reasons.

首先，当我们摄入富含纤维的食物时，会有更强的饱腹感，从而减少热量摄入过量的可能性。

Number one, when we eat fiber rich foods, we're feeling sated, lowering the chance that we're gonna over consume calories beyond what we necessarily need.

这让维持所需热量与摄入热量之间的平衡变得更容易些。

So it just makes it a little bit easier to maintain that balance between the calories that we need and the calories that we're taking it.

因此，从热量密度的角度来看，膳食纤维同样至关重要。

So fiber is important for that reason as well as far as calorie density.

它对我们肠道微生物群和整体肠道健康的直接影响也非常重要。

And it's also important for its direct effects in terms of our gut microbiome, our overall gut health.

关于肠道微生物群仍有许多未知领域，但我们确信膳食纤维是构建健康肠道菌群平衡的关键要素之一。

There's a lot that we need to still understand about the gut microbiome, But we do know that fiber is one of the most important parts of developing a healthy balance of different organisms in our gut flora.

它还能有效调节炎症反应，甚至产生短链脂肪酸等有益分子。

And it's also important for regulating inflammation, even producing molecules like short chain fatty acids.

我们的肠道菌群喜欢代谢膳食纤维。

Our gut bacteria like to metabolize fiber.

它们喜欢代谢各种不同类型的纤维。

They like to metabolize a variety of different types of fibers.

虽然我个人可以整天吃传统燕麦片（你们会经常听我提起），但我知道需要摄入多样化的食物，对吧？

So even though I personally, I could eat old fashioned oats all day long, you'll hear me keep talking about it, I know that I want to eat a diversity of different foods, right?

那些富含纤维的食物。

That contain fiber.

所有这些都很重要。

All of it matters.

所以纤维的作用巨大。

So fiber is huge.

纤维很可能是我们已知的以植物为中心的饮食能有效降低糖尿病风险、并改善糖尿病患者血糖水平的最重要原因之一。

Fiber really is probably one of the biggest reasons that we know that eating plant centered diets can be very effective for lowering the risk of diabetes and also for improving blood sugar in people who have diabetes.

我们还知道多种不同的植物营养素和抗氧化剂、微量营养素如钾、镁等，这些成分就像交响乐般协同作用，共同降低炎症、降低胆固醇，真正解决与胰岛素抵抗和二型糖尿病相关的一些潜在病理过程。

We also know that a variety of different phytonutrients and antioxidants, micronutrients such as potassium, magnesium, all of these, again, it's like a symphony that works well together to lower inflammation, lower cholesterol, and really address some of those underlying processes that are going on with insulin resistance and type two diabetes.

太棒了。

Amazing.

我记得听你演讲时，有个观点深深触动了我，我直接借用了这个说法反复使用——就是'多吃植物'这个概念。

I remember sitting in the audience in one of your talks, and one of the things resonated so deeply with me and I just stole that statement and I'm using it over and over again and it's the concept of just eating more plants.

不要总想着戒断食物，不要想着剥夺自己，就单纯多吃植物——正因为你刚才提到的那些好处：更多纤维、更多植物营养素，这个理念让我深受启发。

Don't think of cutting things out, don't think of deprivation, just eat more plants because of the very things that you just talked about more fiber, more phytonutrients and I loved it.

我特别钟爱这个理念，尤其是当我们面对面指导患者时——比如我在社区开展烹饪课程时，告诉他们'多吃某种食物'听起来就像在赠送礼物。'多吃植物'这个建议能自动保证纤维摄入、植物营养素摄入，并平衡你一天中摄入的其他所有食物，这个想法太美妙了。

I loved it and especially when we're working with our patients face to face or you know I do some cooking sessions in the community telling them to eat more of something sounds like you're giving them a gift and I love that idea you just eat more plants and it automatically takes care of your fiber intake or the phytonutrient intake and just balancing everything else that you're eating in a day.

是的，我认为这种方法对我接触过的大多数糖尿病患者以及其他多种病症患者都非常有效。

Yeah and I think this approach has worked really well for most of my patients that I've talked through who are living with diabetes and with many other conditions.

我认为部分原因还在于这是一种丰盈而非剥夺的饮食方式。

And I think part of it too, is this approach of abundance versus an approach of deprivation.

要让人们能够长期坚持某种饮食方式，它必须是令人愉悦的。

For people to be able to keep something up long term, it has to be enjoyable.

他们不能有被剥夺的感觉。

They cannot feel deprived.

食物必须美味可口。

It has to taste good.

而且他们需要感受到某种丰盈感，对吧？

And they have to feel like there's some abundance, right?

我非常认同这个理念。

I love that.

我特别喜欢这种'自然替代'的饮食方式。

I love the crowding out approach.

我喜欢这个观点：你打算在餐盘里放些什么？

I love what are you going fill your plate with?

而不是总在问：你要戒掉什么？

Not always what are you taking away?

你要削减什么？

What are you cutting?

确实如此，我完全理解为什么他们需要与你这样的团队合作。正如你之前所说，既需要医生来解释病情，也需要注册营养师或社工等人员持续跟进，手把手指导他们理解并执行治疗方案。

Yeah absolutely and I can see why it's important for them to work with a team like you were saying earlier you need someone to tell them what's happening which is usually the physician and then you need someone to hold their hand while they're doing it which is essentially a registered dietitian or some sort of a social worker or some sort of a person that they can touch base with to understand it.

对很多人来说，他们需要这种全方位的干预——从多角度理解概念，在适应期保持耐心，不必过度关注指标的短期波动。因为在过渡阶段，血糖和其他生物标志物可能会出现暂时性升高或异常降低。

For a lot of people they need that comprehensive approach where they're hit from multiple different sides to understand a concept hold themselves in that space for a while not be concerned about some of the numbers going up and down because during the transition you could potentially see some increase or abnormal decrease in glucose and some other biomarkers.

你在临床中是否遇到过这种情况：患者因为前一晚吃了香蕉导致空腹血糖飙升，结果惊慌失措？

Have you experienced that with your patients where they suddenly freak out because their fasting glucose is very high because they had a banana the night before?

是的，我认为这需要大量的心理支持和反复保证——适应需要时间。

Yeah, I think that it takes a lot of support and reassurance that it takes time.

而且我认为每个人的适应过程都是不同的。

And I think that it's different for different people.

这也取决于你一开始所做的改变有多剧烈。

It also depends on how intensive are the changes that you're making right off the bat.

确实有些人能够早期就做出剧烈改变，他们准备好全力以赴，并且拥有这样做的资源和食物获取途径等等。

There are definitely people who can make intensive changes early on and they're ready to go all in and they have the resources to do that and access to the foods and all of that.

他们实际上可以看到血糖下降得相当快。

And they can actually see their blood sugar drop pretty quickly.

对于我照顾的大多数人来说，这是一个循序渐进的过程。

I say for most people that I take care of, it's a process.

它涉及小步骤的调整。

It involves small steps.

我们有时会尝试新食物，或者与你认同的食物打交道——那些属于你成长过程中熟悉的烹饪传统、你喜欢且恰好是营养丰富的植物性食物？

We're working with sometimes trying new foods or working with what are the foods that you identify with that are in your culinary traditions that you grew up eating that you like that happen to be nutritious plant foods?

我们如何将这些食物移到餐盘中央并填满餐盘？

And how can we move those towards the center of the plate and filling the plate?

你如何与家人一起应对这个问题？

How are you working with your family around this?

这在你的预算范围内可行吗？

How is this working within your budget?

这如何安排在你的时间中？

How is this working within your time?

你会做饭吗？

Do you know how to cook?

所有这些事情，很多人都在努力解决。

All of these things, a lot of people are working out.

如果他们只是维持上周的饮食模式，只是多吃些芒果——芒果很棒——但起初他们的血糖会升高。

And so if they're just consuming the same eating pattern they were eating last week, but just adding more mangoes, mangoes are great, but they will see a rise in their blood sugar at first.

这是一个需要时间的过程。

It's a process that takes time.

最常见的障碍是难以获取营养食物，甚至根本难以获取食物。

The barriers that I see most commonly are low access to nutritious foods and really low access to food at all.

另一个常见问题是社区安全感缺失，无法安心外出散步或在户外活动身体。

The other things that I see not feeling safe in one's neighborhood, not being able to go outside and take a walk and feel safe doing so and move your body outside.

他们生活中真正艰难、充满压力的处境，打多份工、缺乏所需支持、身为单亲父母、创伤经历、所有这些因素，以及住房不稳定问题。

Really tough, stressful situations in their life, working multiple jobs, not having the support that you need, being a single parent, history of trauma, all of those things, housing insecurity.

我照顾的病人有些无家可归，有些人虽有住处却没有厨房。

I take care of patients who are homeless or who have a place to live but may not have a kitchen.

因此存在许多情况使得谈论生活方式改变变得异常困难。

So there's a lot of circumstances where it does make it extraordinarily difficult to talk about lifestyle change.

很容易想象——我为什么要提这个？

And it's easy to imagine that why would I even bring this up?

但关于激励因素，我要说当患者来找我时——尤其是刚确诊糖尿病时——我会告诉他们：'我们刚检查了你的血糖和糖化血红蛋白，数值显示是二型糖尿病'，这种时刻非常美好。

The motivators, however, I would say it is wonderful when a patient comes to me and says, especially when they have a new diagnosis of diabetes, and I tell them, we've just checked your blood sugar, your hemoglobin A1C, it's in the range of type two diabetes.

这是个全新的诊断。

This is a brand new diagnosis.

我总是说这是最佳的干预时机，因为通过早期生活方式干预，不仅最有可能改善潜在病情，甚至可能实现缓解——这是我医学生涯中最有成就感的经历之一。

And I always say this is the most beautiful opportunity to intervene because when you intervene early with lifestyle change, you stand the greatest chance of not only improvement in the underlying disease process, but actually remission, which is one of the most rewarding things I've ever seen in my medical career.

所以当我和患者讨论这些时，看到他们眼睛发亮、充满求知欲，当他们找到动力——无论是想...

So when I talk about that with patients and I bring that up and they light up and they're really excited to learn more and they have a reason, whether it's they want to

为了他们的孩子或孙辈保持健康，这是他们内心深处真正的动力。

be healthy for their kids or their grandkids, there's something really driving them intrinsically.

这种力量令人难以置信。

That is incredibly powerful.

太棒了。

Beautiful.

不，我完全同意你的观点。

No, I completely agree with you.

我确实经历过这样的时刻——当你看到患者生活中优先事项清单发生彻底转变时。我总是告诉患者：不要觉得自己是个失败者，这只是一个数据点，接受它并思考如何应对。正是这些微小的、渐进的成功步骤，会让你达到一个更好的控制点，即使不是完全掌控。

I've actually been in those moments where you see a patient's priority the list of the things that are important in their life completely shift and I try to tell my patients like don't feel like a failure it's a piece of data take it in see how you can work around it and it's those small little incremental steps of success that will put you at a point where you have better control, if not fully.

有时你无法完全掌控自己的饮食和生活方式。

Sometimes you don't have full control over your diet and lifestyle.

我们有一定程度的控制力，这就足够了。

We have some measure of control and that is good enough.

这就是我们要求患者做到的全部。

That is all we can ask our patients to do.

确实如此。

Exactly.

我认为在人们改变生活方式的意愿或能力问题上，不应该带有道德说教。

I think there's no place for moralizing around people's ability or willingness to make lifestyle changes.

人们对于是否愿意改变生活方式都有自己的理由，而且他们面临着许多具有挑战性的处境。

People have reasons for why they may be willing or unwilling, and they have a lot of challenging circumstances.

作为一名医生，我觉得我的职责就是尊重患者的目标，让他们知道有哪些可能性，以及我会如何支持他们。

I feel like as a physician, it's my job to just respect what the person's goals are, let them know what's possible and how I'm going to be there to support them.

我曾遇到过一些患者，那是我第一次为他们做初级诊疗，我们简单讨论了他们可以做出的生活方式改变。

I've had patients where it was the first time I met them for a primary care visit, and we talked a little bit about changes that they could make to their lifestyle.

我记得有位患者刚被诊断出糖尿病，同时还患有阻塞性睡眠呼吸暂停。

I remember one patient also had a new diagnosis of diabetes, had obstructive sleep apnea.

临近诊疗结束时，我们时间非常仓促，只简单讨论了一下这个问题。

Towards the end of a visit, we were very, very rushed and we talked a little bit about it.

我当时就觉得，这个人根本不可能做出改变。

And I thought, there's no way this person's making a change.

我只是做了一个假设。

I just made an assumption.

三个月后这位病人回来复诊时，已经完成了所有这些改变。

This person came back to me three months later, hadn't seen all these changes.

我当时想，好吧，那就证明我是错的吧。

I thought, okay, well prove to me wrong.

然后我告诉自己，别再假设了，停止这些假设。

And I thought, stop assuming, just stop assuming.

是啊。

Yeah.

如果一个人没有做出改变，那也没关系。

If a person doesn't make changes, that's okay too.

这是他们的人生，他们的计划。

It's their life, it's their plan.

他们可能在未来才有能力和意愿去改变，而我的工作就是支持他们，并让他们知道当他们准备好时我随时都在。

They may be able and willing to do it later, and it's just my job to support them and let them know that I'm there when they're ready.

是的，完全正确。

Yeah, absolutely.

在糖尿病预防和护理中，关于结构性变革和公平等概念，你学到了哪些经验教训？

What are some of the lessons that you've learned about concepts like structural change and or equity in diabetes prevention and care.

这在对话中有多重要？

How important is that in the conversation?

是的，这非常重要，因为我过去常常使用‘生活方式是2型糖尿病的根本原因’这样的表述，后来我意识到根本原因其实有很多。

Yeah, that's incredibly important because I think I used to use language around lifestyle being the root cause of type two diabetes, And I realized there are so many root causes.

这不仅仅是个人生活方式的问题。

It's not just the person's lifestyle.

事实上，坦白说，更大的根本原因可能是人们面临的结构性环境——他们是否受过教育、有住房、有收入、能获得食物。

In fact, probably honestly, much bigger root causes are the structural circumstances that people face, whether they have education, housing, income, access to food.

所有这些因素才是许多慢性病的真正根源，对吧？

All of those things are really the root drivers of many of our chronic diseases, right?

这就是为什么某些群体的患病风险更高，我们会看到健康差异的存在。

And that's why some groups are at much higher risk and we see health disparities.

这与其说是个人选择的问题，不如说是关于可获得性和可能性。

It's not about individual personal choices so much as what's accessible and what's possible.

如果不了解影响不同生活方式模式的文化驱动因素，不了解他们的家庭状况，我就无法谈论生活方式的改变。

I cannot talk about lifestyle change without understanding some of the cultural drivers that influence different lifestyle patterns, what their family situation is like.

他们可能想要改变生活方式，特别是在饮食模式方面。

They may want to make lifestyle changes, particularly when it comes to eating patterns.

但如果他们的家人不愿意配合这些改变，而家人又一起吃饭或者这个人负责做饭，那将会非常困难。

But if their family isn't wanting to go along with those changes and the family's eating together or the person is the one cooking, that's going to be really hard.

所以所有这些因素在所有人群中确实都起着重要作用。

So all of these things really come to play really in all populations.

是的，我完全同意。

Yeah, I completely agree.

我在我的病人中也遇到过这种情况，这确实相当具有挑战性。

I encounter that in my patients as well and that's pretty challenging.

如果有人坐在临床医生面前说，告诉我该怎么做，我就会去做。

If someone is, you know, sitting in front of a clinician and saying like, just tell me what to do and I'll do it.

如果有人要求具体的饮食改变，我的餐盘在早、中、晚餐应该是什么样子？

If somebody is asking for specific dietary changes, what should my plate look like breakfast, lunch and dinner?

你会如何描述这一点？

How would you describe that?

好问题。

Great question.

我喜欢这个问题。

I love this one.

我想首先明确一点，几乎所有主要专业协会的指南都强调要多吃全谷物、完整水果、蔬菜、豆类（白豆、扁豆、鹰嘴豆不仅营养丰富而且价格实惠），以及健康脂肪而非不健康脂肪来源。

I would say that first of all, I want to make it very clear that really almost all major professional society guidelines emphasize eating more whole grains, more whole fruits, more vegetables, more legumes, white beans, lentils, chickpeas incredibly nutritious and cheap, by the way, and more healthy fats as opposed to unhealthy sources of fat.

健康脂肪包括牛油果、坚果、种子和橄榄油等。

So healthy fats being avocados, nuts, seeds, olive oil.

在这方面，各类指南有着高度的一致性。

There's so much unity in the guidelines around that.

总之就是以植物为主、植物为中心、植物为重点、植物占主导地位，无论怎么称呼都可以。

And that is plant rich, plant centered, plant focused, plant predominant, whatever.

甚至不需要标签。

Don't even have to have a label.

关注这些食物对我们有益，不仅在于预防糖尿病，还能改善糖尿病状况，甚至可能实现糖尿病缓解。

Focusing on those foods is what benefits us, not just in terms of diabetes prevention, but in terms of improvement of diabetes, potential diabetes remission.

但除了糖尿病外，还有糖尿病并发症——您在神经学和脑血管疾病方面有专业背景。

But beyond diabetes, the complications of diabetes, you have a background in neurology and cerebrovascular disease.

您比任何人都清楚生活方式对降低这些风险的重要性。

You know as well as anyone how the importance of lifestyle in lowering those risks.

心血管疾病会降低总体癌症风险。

Cardiovascular disease lowers your risk of total cancer.

当我们这样饮食时，癌症风险会降低，还能减少肾脏疾病的发生率或或延缓已有肾病的进展。

Cancer risk is lowered when we eat this way, lowers your risk of developing kidney disease or kidney disease progression if you already have kidney disease.

好处实在太多了。

There's just so many benefits.

其中许多正是我们糖尿病患者最担忧的健康问题。

Many of these are the things that we worry about in people who are living with diabetes.

是的。

Yeah.

说到餐盘里该放什么食物，我认为考虑餐盘上的均衡搭配很重要。

And then I think in terms of what foods to put on the plate, I think it's important to think about the balance on the plate.

很多时候，当人们考虑增加植物性饮食或在餐盘中加入更多植物时，他们想到的是蔬菜、沙拉和绿叶菜。

A lot of times when people think about eating more plant based or adding more plants to the plate, they think about vegetables and eating more salads and greens.

这些都很好，但你知道吗？

And those are all great, but you know what?

你会饿的。

You're gonna be hungry.

你可能会感觉不舒服，然后就会想，哦，我无法这样生活。

You may not feel good, and then you're gonna think, oh, I can't live that way.

所以你绝对需要去买那种理想的碗盘三明治早餐。

So you definitely need to go buy the ideal bowl plate sandwich breakfast.

你应该选择富含蛋白质的植物性食物。

You should have a protein rich plant food.

所以这可以是，你知道的，豆类食物。

So that could be, you know, your legume category.

有很多植物性食物富含蛋白质，你需要确保摄入富含蛋白质的植物性食物，约占餐盘的四分之一，或者根据人生不同阶段的蛋白质需求有所调整。

There's a lot of plant foods that are very rich in protein, and you want to make sure you're having a protein rich plant food, about a quarter of the plate or in some cases, people have different protein requirements depending on stage of life.

你还需要一个健康的碳水化合物来源。

You also need a healthy carbohydrate source.

可以是淀粉类蔬菜，比如红薯。

That could be a starchy vegetable like a sweet potato.

也可以是谷物。

That could be grains.

可以是藜麦、糙米，甚至常被诟病的白米。

That could be your quinoa, your brown rice, even your white rice, which is often maligned.

对。

Right.

但当你将白米（这是许多人的文化传统主食）与富含纤维的豆类搭配食用时，就能补充大量纤维。

But when you're combining white rice, which is cultural tradition for many, many people, and you're adding more fiber in terms of beans with your rice, you're getting a lot of the fiber back.

但关键在于餐盘上的均衡搭配。

But it's really about the balance on the plate.

重点是要实现某种平衡。

It's about let's achieve some balance there.

这样你还能有充足空间选择你喜欢的非淀粉类蔬菜。

And then you have a lot of room still left for your non starchy vegetables, whichever ones you like.

说实话，我最爱西葫芦、抱子甘蓝、芦笋和绿叶蔬菜。

My favorite, honestly, zucchini, brussels sprouts, asparagus, leafy greens.

这些都是绝佳选择。

All of those are great.

别忘了水果。

And don't forget about the fruit.

水果非常棒。

The fruit is wonderful.

我觉得人们对水果有很多误解，就像我们最初讨论的那样。

I think fruit is there's a lot of misconceptions like we started off talking about that.

水果非常棒。

Fruit is fantastic.

水果与降低糖尿病风险相关。

Fruit is linked to lower risk of diabetes.

它与糖尿病患者并发症风险降低相关。

It's linked to lower risk of complications in people who have diabetes.

但最好直接咀嚼食用而非榨汁，这样才能真正保留所有纤维。

But it is best chewed rather than in the form of juice where you're really preserving all the fiber.

所以你是想说葡萄不是糖衣炮弹吗？

So you're trying to say that grapes are not sugar torpedoes?

没有香蕉我活不下去。

I couldn't live without bananas.

我永远不会建议过没有香蕉的生活。

I would never recommend living without bananas.

我只是在用某些人使用的术语——他们用危言耸听的方式谈论水果，但水果明明这么神奇。

I'm just using terminologies that are used by some people is fear mongering over fruit but they're so amazing.

光是听这些就让我既感到饥饿又满足，因为它们太美好了，尤其是多吃豆类的理念——在我们家，如果蔬菜旁边没有豆子、鹰嘴豆或扁豆，我们就觉得不满足。

I feel hungry and satiated just listening to all of those things because they're wonderful and especially the concept of eating more legumes because in our household if there's no bean or chick pea or lentil next to our veggies, we don't feel satiated.

它们含有丰富的纤维、蛋白质和优质碳水化合物，而且非常美味。

They have so much fiber in them and protein and good carbs and it's just delicious.

许多研究表明，经常食用豆类的人寿命更长。

And many studies have shown that people who consume legumes on a regular basis live longer.

他们大脑更健康，心脏功能更好，对糖尿病和糖代谢的控制也更佳。

They have better brain health, better heart heart health, better control of diabetes and their sugar metabolism.

这些都是好消息。

So this is all great news.

我很想听听你对GLP-1激动剂类减肥药物（如Ozempic和Mounjaro）的看法。

I would love to hear your take on the popular weight loss drugs like GLP-one agonists like Ozempic and Mounjaro.

你觉得怎么样？

What do you think about that?

听着，我认为这些是极其强大的药物，正在彻底改变肥胖症和2型糖尿病患者的治疗方式，就这么简单。

Listen, I think these are incredibly powerful drugs that are revolutionizing the care of people who are living with obesity and type two diabetes, period.

有些人认为，哦，那是在作弊，或者你不应该服用那些药物。

There's people who are thinking, oh, that's cheating, or you shouldn't go on those medications.

你应该完全靠自己通过生活方式来改变。

You should just do it all yourself with lifestyle.

还有一些人完全忽视了生活方式，认为只要服用这种药物，体重就会下降，血糖会改善，我再也不用担心饮食或生活方式了。

And then there's people who really forget about lifestyle and I can just take this medication and the weight will come off, my blood sugar will improve, and I never have to worry about what I eat or my lifestyle.

显然这是两种极端。

And obviously those are two extremes.

现实情况是，如果你正在服用GLP-1药物来应对体重问题或二型糖尿病——这些是目前这类药物的适应症——它必须与生活方式干预相结合。

And the reality is if you're taking a GLP-one medication for concerns about weight or for type two diabetes, which are the indications right now for these medications, it needs to be paired with lifestyle.

这也是指南中的要求。

That's also in the guidelines.

这样做效果更好，它不仅有助于整体健康，在很多情况下还能帮助人们更好地发挥药物疗效。

People do better and it supports overall health in addition to helping you, in many cases, helps people actually do better on the medication.

事实上，我认为最近刚出台了一份临床实践指南或声明，专门强调营养的重要性——当人们服用GLP-1药物时，哪些饮食模式有助于减少药物副作用。

So there's actually, I believe, a clinical practice guideline or statement that just came out about nutrition, how important that is when people are taking GLP-1s and what types of eating patterns can support reducing side effects in people with GLP-1s.

所以这是一个完整的领域，但我认为两者结合非常重要。

So that's a whole area, but I think they're both really important together.

你知道，我对GLP-1类药物有一些担忧，主要是关于公平性问题。

You know, I have a few concerns about GLP-1s, but primarily around the equity piece.

这些药物对我们许多人群来说是无法获得的，尤其是当我们讨论体重问题时。

These are medications that are not accessible to many parts of our population, particularly when we're talking about weight.

如果一个人没有糖尿病，许多保险公司不会批准使用这些药物，而且它们价格昂贵。

If a person does not have diabetes, they're not approved by many insurance companies and they're expensive medications.

因此，不仅很多人无法获得这些药物，而且按照目前的情况，如果将其用于整个人群，成本将极其高昂。

So not only are they not accessible to a lot of people, but for us to use them as they may be indicated for the entire population would be extraordinarily expensive as they are right now.

所以我认为我们现在的处境是：我们认识到这些药物的强大功效。

So I think we're in a situation where we recognize how powerful these medications are.

但我们也意识到，当一个人发展到患有二型糖尿病或临床严重肥胖（三级肥胖）时，这些药物虽然能解决基础生理问题，但我们在预防方面还需要做更多工作。

But we also recognize that once a person gets to the point where they have type two diabetes or clinically severe obesity, class three obesity, these are medications that are helpful and address the underlying physiology, but we have to do so much more work in terms of prevention.

完全同意。

Absolutely.

而且，你知道，我们有很多事情要做，你是一个了不起的榜样，为医疗系统做出了很多贡献，甚至在州级层面也是如此。

And, you know, we have a lot to do and you're such an amazing role model of someone who has done a lot for the healthcare system, even at the state level.

我想在结束这次对话时请教你，如果要从零开始重新设计医疗系统对糖尿病的应对方式，你会优先考虑哪些方面来真正改变治疗结果？

I would love to wrap this conversation by asking you if you could redesign the healthcare system's approach to diabetes from scratch, what would be some of the things that you would prioritize to truly transform outcomes?

这是个宏大的问题。

That's a lofty question.

根据我的经验，真正具有变革性的是团队协作的医疗模式，团队包括医疗提供者、注册营养师、健康教练、社区卫生工作者等成员，我们为患者提供全方位的生活方式支持，关注他们的整体健康。

I can say from my experience, what has been transformative is team based care, where the team includes a medical provider, registered dietitian, other staff like health coaches, community health workers, a dream team where we're really providing patients with access to all of these different aspects of lifestyle and looking at the whole person and their overall well-being.

在背景层面，我们当然要继续倡导解决那些阻碍人们获取健康食物的社会因素和政策问题。

On the background, of course, we're continuing advocacy towards addressing some of those social drivers and policies that don't allow for people to have access to healthy food.

这些都是背景工作。

That's all in the background.

但就医疗本身而言，我们希望帮助人们解决如何获取健康食物的问题。

But in terms of the healthcare piece itself, we wanna be able to support people in how do we get people access to healthy food?

我们该如何实现所有这些目标？

How do we do all those things?

我们将这些融入团队建设和社会工作社区卫生工作者的工作中。

And we build that into the team and our social work community health workers.

然后我们构建方法，通过医生、注册营养师、健康教练等渠道真正定制生活方式教育，持续为人们提供支持和激励。

And then we build in ways to really tailor lifestyle education through physicians, registered dietitians, health coaches, and really keep people supported and motivated.

她是不是很棒？

Isn't she amazing?

她确实非凡绝伦——在这个世界上，即便不是全部，绝大多数诊所和医院都不涉及生活方式干预，而她却在全美最大的医疗系统之一中推行这项事业，覆盖六个不同地区且规模不断扩大。

She's absolutely remarkable because in a world where most clinics, if not most, all clinics and all hospitals don't even address lifestyle, She's doing it in one of the largest health systems in the country and she's doing it across six different places and it's growing.

这需要非凡的韧性、沟通能力和领导力才能让这项事业落地生根并发展壮大。

It takes that level of resilience, that level of communication and leadership that could make this land and grow.

她简直令人惊叹。

She's absolutely amazing.

她确实如此。

She really is.

医生。

Doctor.

西奥多·弗里德曼，我们本期的第三位也是最后一位嘉宾，将讨论糖尿病、胰岛素抵抗、获取如Ozempic等药物以及社会污名如何影响临床系统中的糖尿病管理。

Theodore Friedman, our third and final guest for this episode, discusses how diabetes, insulin resistance, access to medications like Ozempic, and social stigmas affect diabetes management within clinical systems.

他是查尔斯·R·德鲁医科大学与科学大学及加州大学洛杉矶分校的内科教授兼系主任。

He's a professor and a chair of the department of internal medicine at Charles R.

他是我们的同事，对社区和患者怀有深切关怀。

Drew University of Medicine and Science and UCLA.

他深切关心社区和他的病人们。

He's our colleague, and he deeply cares about communities and his patients.

这是我们的对话。

Here's our conversation.

Friedman医生，非常高兴您能来到这里与我们交流。

Doctor Friedman, it is wonderful to have you here with us.

我认识您大约有一年半到两年的时间了。

I've known you for about, what is it, about a year and a half, two years now.

说实话，我非常欣赏您的工作和使命。

And I, to be honest, I love the work you do and your mission.

告诉我是什么让你走到今天这一步的？

Tell me what brought you to this point?

你是怎么最终来到查尔斯·德鲁大学并专门从事糖尿病研究的？

How did you end up at Charles Drew and specifically working in diabetes?

好的，这是个好问题。

Okay, that's a good question.

我想这是个很长的问题。

A long question, I think.

我在几十年前就决定进入内分泌学领域。

I decided to go into endocrinology many decades ago.

我的博士学位论文研究的是处理TRH的一种酶，并发现了一种新酶。

My PhD was on an enzyme that processed TRH and discovered a new enzyme.

这让我对脑激素产生了兴趣。

It made me interested in brain hormones.

我认为当时有很多研究机会，也有很多方法可以改善人们的生活质量，真正改变他们的健康状况。

I think there was a lot of opportunities for research and there was a lot of ways to influence people's quality of life, really make a difference in their health.

那时候糖尿病根本不在我的考虑范围内。

Diabetes was not on my map at all back then.

我在美国国立卫生研究院完成了研究员工作，研究加工酶。

I did my fellowship at the NIH, worked on processing enzymes.

我们对糖尿病了解了一点，但那时候它确实没那么有趣。

We learned a little bit about diabetes, but it certainly wasn't that interesting then.

当时治疗糖尿病的药物并不多。

There wasn't that many medicines for it.

大约就在那时，糖尿病并发症研究结果出炉了。

The diabetes complications study came out around that time.

差不多就在那个时期，人们才开始意识到控制糖尿病很重要。

It was really just about that time people started realizing that diabetes control is important.

我们基本上只有二甲双胍、胰岛素和磺脲类药物，所以治疗药物并不多。

We had metformin and insulin basically and the sulfonylurea from medicine, so not too many medicines.

我后来成为了门诊中心糖尿病与内分泌诊所的负责人，并于2008年担任查尔斯·德鲁医学部主席。

I became the head of the diabetes and endocrinology clinic in the outpatient center and became chairman of medicine Charles Drew in 2008.

之后我成为了洛杉矶县卫生服务部健康服务局DHS内分泌糖尿病工作组的主任。

And then I became the director of the DHS Endocrinology Diabetes Workgroup, Department of Health Services, Los Angeles County Department Health Services.

这是一个庞大的机构，拥有60万名低收入患者。

It's a large organization with 600,000 patients, low income patients.

我想我们最初以为会处理很多内分泌问题，但实际上主要治疗糖尿病，因为我们的系统中有大量糖尿病和肥胖患者。

I think we originally thought we would do a lot of endocrinology, but we really do mostly diabetes because there's so many patients with diabetes, obesity in our system.

我们致力于制定预期实践标准，确定哪些药物应列入处方集，以及如何使糖尿病护理更具成本效益。

And we work on trying to figure out expected practices, what medicines should be on formulary, how to make diabetes care cost effective.

这些患者往往有很多并发症，而这种疾病本可以很大程度上预防。

These are people that have a lot of complications, and it's a very preventable disease.

我要讲一个关于我妻子高中同学的插曲。

I'll tell a side story about my wife's high school classmate.

一个悲伤的故事。

A sad story.

我妻子已经几十年没和她联系了。

My wife wasn't in touch with her for decades.

她一直很肥胖。

She was always obese.

后来我妻子与她重新联系上时，她已经经历了截肢、透析和溃疡。

And then my wife reacquainted with her, and she had amputations, dialysis, ulcers.

因此只能依靠轮椅生活，这都是糖尿病导致的。

So was wheelchair bound, all from her diabetes.

听起来这些年她患糖尿病期间似乎从未看过医生。

And it didn't sound like she really saw any doctor for all these years of her diabetes.

我想如果她能及时就医，医生本可以预防并控制她的糖尿病，她现在还能保住双腿和肾脏，这原本是可预防的疾病。

I think if she could have seen somebody and they started preventing her diabetes and getting it under control, she'd still have her legs, she'd still have her kidneys, and this, again, is a preventable disease.

所以我认为类似的故事还有数百万例。

So I think there's millions of stories like that out there.

糖尿病患者正在增加，约占人口的百分之十。

Diabetes is growing, it's about ten percent of the population.

这与肥胖密切相关，而肥胖也正在成为一种流行病。

It's very tied into obesity, and obesity is becoming an epidemic also.

因此，如果我们能设法让人们保持健康、改善饮食，我认为我们确实能对这种疾病产生重大影响。

So if we can try to look at ways to get people to be healthy, get them to eat better, I think you can really make a dent in this disease.

这太棒了。

That's wonderful.

这正是我们想听到的——这段历程。

That's exactly what we want to hear is the journey.

让人们看到医生们的热情和他们所经历的旅程，不仅仅是与人群之间冰冷的联系，而是我们实际上有着个人故事和个人情感纽带。

And for people to see the passion that the doctors have and the journey they have is not just this very cold connection with the population, but it's actually we have personal stories, personal connections.

我们经常讲述阿伊莎和我都有两位祖父母因阿尔茨海默病去世的故事，实际上我们多年后才意识到这件事的影响。

We always tell the story of both Ayesha and I having two grandparents that died from Alzheimer's, and we actually didn't know what the influence was until after many years afterwards.

就像，好吧。

Were like, okay.

那就是最初的动力。

That was the impetus.

这就是推动我们寻找治愈方法和预防途径的根源。

That was the nidus of this drive to find some cure, some pathways of prevention.