In Focus
For more on strategies to fight obesity in Mexico see http:// wphna.org/v2/wp-content/ uploads/2013/06/13_Obesity_ in_Mexico_Book_Rivera_et_al1. pdf
risk factors or previous diagnosis of diabetes or obesity. The third pillar is regulation and fiscal policy for health, which includes a tax on sugary drinks and on basic foods with high caloric density. The tax on sugary drinks has been heavily covered in the Mexican media in the past 3 months. It was approved on Oct 31 by the Congress of the Union and consists of a one peso (about US$0·07 or £0·04) tax on every litre of sugary beverages. The tax is part of a fiscal reform package, which also includes a levy of 8% tax on junk food (classified as products that contain 275 kcal or more for every 100 g). “The purpose of these taxes is to reduce the consumption of these products, which are associated with the increase in overweight and obesity prevalence in Mexico”, commented Peña Nieto. But the tax by itself might not be enough to make a noticeable change since sugary drinks are linked to a perceived socioeconomic status in Mexico, especially in the poorest populations. “Buying a sugary drink shows that you have the ability to buy, which reflects some kind of success”, explains UrquÍa. At the moment, very few people in rural areas are buying
bottled water, but many of them are willing to buy a sugary drink. Access to drinking water for all populations, improvement of water delivery systems, and strong marketing of water consumption should help improve people’s perception of drinking water. Taking all these factors into account, Peña Nieto noted that to enhance the favourable effect of this tax reform, a substantial part of the collection of these taxes should be spent on prevention programmes and on measures to increase the access to drinking water in schools. Finally, by contrast with the crackdown on bad nutrition, incentives for producers of healthy foods are also being introduced. A “nutritional quality” stamp was also mentioned as part of the new Government strategy. This stamp will be given to producers who meet high nutritional standards. The aim of this stamp is to create an additional incentive for the industry to reformulate their products or generate more healthy options. As expected, Mexico’s fiscal reform and strategy to fight obesity was strongly contested by the industry. However, Brian Smith, President of the Coca-Cola Company Group in
Latin America, announced at the launch that, as a contribution to abate obesity, the company is focusing on the development of soft drinks without—or low in—calories, and on the total transparency of nutritional information on their packaging. Also, they committed to responsible marketing and sales guidelines in schools, and pledged not to direct their marketing to children younger than 12 years. Mexico has shown a strong engagement to tackle obesity and overweight in the country so far, but much remains to be done. “The impact of obesity and diabetes in Mexico is huge, and the actions to be taken are multiple”, noted Carlos Aguilar Salinas, of the National Institute of Medical Science and Nutrition, Mexico City. As the President passionately put it: “It’s time to change individual and collective habits. It’s time to change, to move, and to transform Mexico.” Mexico’s efforts could be a good example for other countries in Latin America facing a similar epidemic and looking for a change.
Olaya Astudillo
Bureau L.A. Collection/CORBIS
Sending me up, sending me down
Published Online December 5 2013 http://dx.doi.org/10.1016/ S2213-8587(13)70163-3
16
Actor Tom Hanks recently revealed that he has been diagnosed with type 2 diabetes. Hanks, half-seriously, attributed his diagnosis to the fact that he has often gained and lost large amounts of weight in a short space of time for film roles. For example, Hanks gained 14 kg to bulk up for a role in the 1992 baseball film A League of Their Own, lost 12 kg to play a lawyer with AIDS in the 1993 film Philadephia, lost weight again for 1994’s Forrest Gump, and gained and then lost 25 kg in a year to play a shipwrecked survivor of a plane crash in the 2000 film Cast Away. The gruelling demands of filming schedules and red carpet launches mean that the speed at which actors
must gain or lose weight is nearly as frightening as the amount, and certainly Hanks is not the only major actor who has put his body through serious changes. For The Machinist, Christian Bale lost 28 kg to achieve a skeletal 55 kg bodyweight, but within 5 months had gained 45 kg to play the defender of Gotham City in Christopher Nolan’s reimagining of the Batman franchise Batman Begins. Other stories of Hollywood weight manipulation abound. Many female actors must also change their weight in short spaces of time—for example, Renée Zellweger famously gained weight to play Bridget Jones in the adaptation of
Helen Fielding’s novel—but they tend to feature less often in stories of dramatic weight gain, partly because the weight gain is often relative to what is average for most of the population (in Zellweger’s case, she gained about 9 kg to a UK dress size of 14), and partly because women are the protagonists of very few Hollywood films. Does weight fluctuation confer a substantial risk of health problems such as diabetes in later life? Jocilyn Bergin, who researches the genetic epidemiology of psychiatric illnesses and behavioural risk factors (Virginia Commonwealth University, Richmond, VA, USA), thinks that
www.thelancet.com/diabetes-endocrinology Vol 2 January 2014
In Focus
the hypothalamus, a key brain area involved in metabolism”, Kahn says. The hypothalamus is involved in the hormonal regulation of appetite, and findings from a 2012 study of mice fed high-fat and high-sucrose diets showed structural changes to the hypothalamus (including immune activation and angiopathy). Kahn also suggests that macronutrient deficiencies and changes in the microbiome induced by sudden changes in diet might hypothetically affect diabetes risk, although he is sceptical that these elements substantially affect the likelihood of any individual developing diabetes. “Genetics and obesity are still the biggest risk factors for getting diabetes”, he says. Relatively little is known about the long-term and short-term effects of BMI fluctuation. “There have been several studies which have indicated that BMI fluctuation is associated with depression, cardiovascular disease, hypertension, metabolic syndrome components, and diabetes”, says Bergin. “Studies have also shown that an increased risk of death from cardiovascular disease has been associated with BMI fluctuation. These findings are similar to what has been established for obesity; however, thus far obesity has been more thoroughly studied.”
In view of the potential health effects of rapid weight gain and loss, in addition to the much better understood harms from obesity (which include musculoskeletal damage, depression, and respiratory problems), is it ethical for directors to demand that actors achieve particular body types for what is, fundamentally, a form of entertainment? Beyond very high-profile cases of successful actors such as Hanks, the implications of weight fluctuation for actors’ health in general is not clear. Actors are notoriously underemployed—perhaps only one in ten are in work at any one time—and the huge number of potential casting choices might make the notion of making the actor fit the part, rather than finding an actor of the appropriate size, to be a niche problem. However, the lack of employment opportunities might put actors into vulnerable positions, afraid to say no to a job that involves substantial physical changes. More research into BMI fluctuation, unpicking the effects of intended weight change (eg, through dieting or deliberate overeating) from unintended, and that of fat gain from muscle bulking, is needed; meanwhile, actors will continue to suffer pizza and melted ice cream as occupational hazards.
For Bergin’s study into risk factors for type 2 diabetes see Behav Genet 2012; 42: 867–74 For the study of mice fed high-fat diets see Mol Metab 2012; 1: 95–100
Hannah Cagney
Bureau L.A. Collection/CORBIS
it might. “While it is impossible to discover precisely what caused the onset of diabetes for Tom Hanks, research has shown that BMI fluctuation, like losing and gaining weight for his roles in various films, could have been a contributory factor”, she says. In 2012, she was the lead author of a study into risk factors for type 2 diabetes with 26 808 individuals. Participants self-reported diagnoses of various diseases (including diabetes), current height, current weight, highest weight, lowest weight, age, and sex. “After controlling for inclusion of related individuals, BMI, and age (all established risk factors for type 2 diabetes), BMI fluctuation was still significantly associated with the development of diabetes. Further, there was a suggestion that BMI fluctuation was among the most important factors in the development of diabetes in one study.” Genetic factors could make the association more complex, because the risk of an individual developing diabetes, high BMI, or BMI fluctuation are affected by genetics. In Bergin’s study, 34% of the variation in BMI fluctuation in men and about 43% of that in women was due to genetic factors, and the genetic component of diabetes and obesity is well established. “Weight cycling is not likely to be a good thing if you’ve got a genetic predisposition”, says Steven Kahn, a diabetes researcher (Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA), pointing out that actors who have to gain large amounts of weight in a short amount of time also might eat unhealthily (eg, consuming high-fat diets) in ways that contribute to diabetes risk. Indeed, Hanks reportedly ate pizza to gain weight for roles, and Jared Leto gained 30 kg by drinking melted ice cream mixed with olive oil and soy sauce to play Mark David Chapman, the killer of John Lennon, in the film Chapter 27. “In animal models, highfat diets have been shown to damage
Tom Hanks has both gained and lost weight for film roles over the past three decades. He lost weight to play Forrest Gump in the 1994 film, and gained weight to play Jimmy Dugan in 1992’s A League of Their Own (margin image).
www.thelancet.com/diabetes-endocrinology Vol 2 January 2014
17
For more on strategies to fight obesity in Mexico see http:// wphna.org/v2/wp-content/ uploads/2013/06/13_Obesity_ in_Mexico_Book_Rivera_et_al1. pdf
risk factors or previous diagnosis of diabetes or obesity. The third pillar is regulation and fiscal policy for health, which includes a tax on sugary drinks and on basic foods with high caloric density. The tax on sugary drinks has been heavily covered in the Mexican media in the past 3 months. It was approved on Oct 31 by the Congress of the Union and consists of a one peso (about US$0·07 or £0·04) tax on every litre of sugary beverages. The tax is part of a fiscal reform package, which also includes a levy of 8% tax on junk food (classified as products that contain 275 kcal or more for every 100 g). “The purpose of these taxes is to reduce the consumption of these products, which are associated with the increase in overweight and obesity prevalence in Mexico”, commented Peña Nieto. But the tax by itself might not be enough to make a noticeable change since sugary drinks are linked to a perceived socioeconomic status in Mexico, especially in the poorest populations. “Buying a sugary drink shows that you have the ability to buy, which reflects some kind of success”, explains UrquÍa. At the moment, very few people in rural areas are buying
bottled water, but many of them are willing to buy a sugary drink. Access to drinking water for all populations, improvement of water delivery systems, and strong marketing of water consumption should help improve people’s perception of drinking water. Taking all these factors into account, Peña Nieto noted that to enhance the favourable effect of this tax reform, a substantial part of the collection of these taxes should be spent on prevention programmes and on measures to increase the access to drinking water in schools. Finally, by contrast with the crackdown on bad nutrition, incentives for producers of healthy foods are also being introduced. A “nutritional quality” stamp was also mentioned as part of the new Government strategy. This stamp will be given to producers who meet high nutritional standards. The aim of this stamp is to create an additional incentive for the industry to reformulate their products or generate more healthy options. As expected, Mexico’s fiscal reform and strategy to fight obesity was strongly contested by the industry. However, Brian Smith, President of the Coca-Cola Company Group in
Latin America, announced at the launch that, as a contribution to abate obesity, the company is focusing on the development of soft drinks without—or low in—calories, and on the total transparency of nutritional information on their packaging. Also, they committed to responsible marketing and sales guidelines in schools, and pledged not to direct their marketing to children younger than 12 years. Mexico has shown a strong engagement to tackle obesity and overweight in the country so far, but much remains to be done. “The impact of obesity and diabetes in Mexico is huge, and the actions to be taken are multiple”, noted Carlos Aguilar Salinas, of the National Institute of Medical Science and Nutrition, Mexico City. As the President passionately put it: “It’s time to change individual and collective habits. It’s time to change, to move, and to transform Mexico.” Mexico’s efforts could be a good example for other countries in Latin America facing a similar epidemic and looking for a change.
Olaya Astudillo
Bureau L.A. Collection/CORBIS
Sending me up, sending me down
Published Online December 5 2013 http://dx.doi.org/10.1016/ S2213-8587(13)70163-3
16
Actor Tom Hanks recently revealed that he has been diagnosed with type 2 diabetes. Hanks, half-seriously, attributed his diagnosis to the fact that he has often gained and lost large amounts of weight in a short space of time for film roles. For example, Hanks gained 14 kg to bulk up for a role in the 1992 baseball film A League of Their Own, lost 12 kg to play a lawyer with AIDS in the 1993 film Philadephia, lost weight again for 1994’s Forrest Gump, and gained and then lost 25 kg in a year to play a shipwrecked survivor of a plane crash in the 2000 film Cast Away. The gruelling demands of filming schedules and red carpet launches mean that the speed at which actors
must gain or lose weight is nearly as frightening as the amount, and certainly Hanks is not the only major actor who has put his body through serious changes. For The Machinist, Christian Bale lost 28 kg to achieve a skeletal 55 kg bodyweight, but within 5 months had gained 45 kg to play the defender of Gotham City in Christopher Nolan’s reimagining of the Batman franchise Batman Begins. Other stories of Hollywood weight manipulation abound. Many female actors must also change their weight in short spaces of time—for example, Renée Zellweger famously gained weight to play Bridget Jones in the adaptation of
Helen Fielding’s novel—but they tend to feature less often in stories of dramatic weight gain, partly because the weight gain is often relative to what is average for most of the population (in Zellweger’s case, she gained about 9 kg to a UK dress size of 14), and partly because women are the protagonists of very few Hollywood films. Does weight fluctuation confer a substantial risk of health problems such as diabetes in later life? Jocilyn Bergin, who researches the genetic epidemiology of psychiatric illnesses and behavioural risk factors (Virginia Commonwealth University, Richmond, VA, USA), thinks that
www.thelancet.com/diabetes-endocrinology Vol 2 January 2014
In Focus
the hypothalamus, a key brain area involved in metabolism”, Kahn says. The hypothalamus is involved in the hormonal regulation of appetite, and findings from a 2012 study of mice fed high-fat and high-sucrose diets showed structural changes to the hypothalamus (including immune activation and angiopathy). Kahn also suggests that macronutrient deficiencies and changes in the microbiome induced by sudden changes in diet might hypothetically affect diabetes risk, although he is sceptical that these elements substantially affect the likelihood of any individual developing diabetes. “Genetics and obesity are still the biggest risk factors for getting diabetes”, he says. Relatively little is known about the long-term and short-term effects of BMI fluctuation. “There have been several studies which have indicated that BMI fluctuation is associated with depression, cardiovascular disease, hypertension, metabolic syndrome components, and diabetes”, says Bergin. “Studies have also shown that an increased risk of death from cardiovascular disease has been associated with BMI fluctuation. These findings are similar to what has been established for obesity; however, thus far obesity has been more thoroughly studied.”
In view of the potential health effects of rapid weight gain and loss, in addition to the much better understood harms from obesity (which include musculoskeletal damage, depression, and respiratory problems), is it ethical for directors to demand that actors achieve particular body types for what is, fundamentally, a form of entertainment? Beyond very high-profile cases of successful actors such as Hanks, the implications of weight fluctuation for actors’ health in general is not clear. Actors are notoriously underemployed—perhaps only one in ten are in work at any one time—and the huge number of potential casting choices might make the notion of making the actor fit the part, rather than finding an actor of the appropriate size, to be a niche problem. However, the lack of employment opportunities might put actors into vulnerable positions, afraid to say no to a job that involves substantial physical changes. More research into BMI fluctuation, unpicking the effects of intended weight change (eg, through dieting or deliberate overeating) from unintended, and that of fat gain from muscle bulking, is needed; meanwhile, actors will continue to suffer pizza and melted ice cream as occupational hazards.
For Bergin’s study into risk factors for type 2 diabetes see Behav Genet 2012; 42: 867–74 For the study of mice fed high-fat diets see Mol Metab 2012; 1: 95–100
Hannah Cagney
Bureau L.A. Collection/CORBIS
it might. “While it is impossible to discover precisely what caused the onset of diabetes for Tom Hanks, research has shown that BMI fluctuation, like losing and gaining weight for his roles in various films, could have been a contributory factor”, she says. In 2012, she was the lead author of a study into risk factors for type 2 diabetes with 26 808 individuals. Participants self-reported diagnoses of various diseases (including diabetes), current height, current weight, highest weight, lowest weight, age, and sex. “After controlling for inclusion of related individuals, BMI, and age (all established risk factors for type 2 diabetes), BMI fluctuation was still significantly associated with the development of diabetes. Further, there was a suggestion that BMI fluctuation was among the most important factors in the development of diabetes in one study.” Genetic factors could make the association more complex, because the risk of an individual developing diabetes, high BMI, or BMI fluctuation are affected by genetics. In Bergin’s study, 34% of the variation in BMI fluctuation in men and about 43% of that in women was due to genetic factors, and the genetic component of diabetes and obesity is well established. “Weight cycling is not likely to be a good thing if you’ve got a genetic predisposition”, says Steven Kahn, a diabetes researcher (Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA), pointing out that actors who have to gain large amounts of weight in a short amount of time also might eat unhealthily (eg, consuming high-fat diets) in ways that contribute to diabetes risk. Indeed, Hanks reportedly ate pizza to gain weight for roles, and Jared Leto gained 30 kg by drinking melted ice cream mixed with olive oil and soy sauce to play Mark David Chapman, the killer of John Lennon, in the film Chapter 27. “In animal models, highfat diets have been shown to damage
Tom Hanks has both gained and lost weight for film roles over the past three decades. He lost weight to play Forrest Gump in the 1994 film, and gained weight to play Jimmy Dugan in 1992’s A League of Their Own (margin image).
www.thelancet.com/diabetes-endocrinology Vol 2 January 2014
17
