"Les Intouchables,” having broken box office records in France, arrives in the United States with a faithfully translated title — “The Intouchables” — that is not quite English. American audiences looking for a suitable French name for this ingratiating comedy of cross-racial friendship might settle on “Déjà Vu,” since it is a story we have seen many times before.
Though maybe not quite like this, or at least not in a while. “The Intouchables,” directed by Olivier Nakache and Eric Toledano and based on a true story, is about two men — one rich, uptight and white; the other poor, exuberant and black — who become best pals in spite of their differences. In place of the customary spoiler alert I will post a cliché warning, since some of the movie’s groan-inducing turns of plot may require equally groan-inducing turns of phrase. I wish I could say them all in French. Or maybe I don’t.
But anyway. The pallid aristocrat, Philippe (François Cluzet), is paralyzed from the neck down as the result of a hang-gliding accident and lives in a state of opulent ennui attended by a nervous staff and is ignored by his petulant adolescent daughter. He is a difficult boss, and his newest employee, a streetwise hoodlum named Driss (Omar Sy) does not look as though he will last long in the job. Not that Driss has much ambition to play nurse for some grouchy old invalid; he applies for the position only so he can continue to collect government benefits. Moving into Philippe’s mansion, Driss steps away from a background of poverty, family dysfunction and trouble with the police. Under his boss’s stern gaze and imperious tutelage he starts to acquire a work ethic and a sense of discipline. In exchange, he helps Philippe discover his appetite for life and his capacity for joy.
How does Driss do this? In the usual ways. He flirts shamelessly with the boss’s secretary and gives Philippe’s daughter the stern talking-to she needs. He introduces Philippe to the pleasures of marijuana, encourages him to start dating and loosens up a stuffy chamber-music soiree with some funky music. Sacre bleu! Nothing is funnier than watching a roomful of buttoned-up white people trying to shake their booties. Look at them! It’s like they have no natural rhythm at all.
It is possible to summarize the experience of watching “The Intouchables” in nine words: You will laugh; you will cry; you will cringe. The caricatures are astonishingly brazen, as ancient comic archetypes — a pompous master and a clowning servant right out of Molière — are updated with vague social relevance, an overlay of Hollywood-style sentimentality and a conception of race that might kindly be called cartoonish.
You can easily imagine this movie — you probably have already seen it — with Richard Pryor or Eddie Murphy in Mr. Sy’s role. In the post-civil-rights, post-blaxploitation era, entertainments based on the clash of white squareness and black soul had a certain novelty and charm. Nowadays they are more likely to be layered with self-consciousness, winking at their own conventions.
In the old days the French view of America’s race problem (as it used to be called) was tinged with pity and superiority. African-American artists and intellectuals — Josephine Baker, Richard Wright, James Baldwin and too many jazz musicians to name — went to Paris to find respect and relief from the bigotry at home, and many contemporary French observers took this fact as confirmation of their own country’s relative innocence. More recently, as France has grappled with immigration and its rapidly evolving identity as a multicultural society, such smugness has dropped away, and much of the best recent French film and literature grapples earnestly with this new situation.
What “The Intouchables” does cannot exactly be called grappling, and its genial parade of stereotypes may be more regressive than liberating. It is certainly possible to be offended by the broad, silly aspects of Mr. Sy’s performance. An English-language remake might be perfect for Tracy Jordan of “30 Rock,” the star of such nonexistent, barely exaggerated blockbusters like “Who Dat Ninja” and “Black Cop, White Cop.” But it is equally difficult to resist Mr. Sy’s charm and inventiveness, or to ignore the sensitivity beneath them.
It is too much to say that he and Mr. Cluzet, a crafty and insightful actor, rescue “The Intouchables.” They do provide it with humanity and idiosyncrasy — with the sense that Philippe and Driss might be real people rather than sociological ciphers — but this film can only be described, in the context of French cinema and global popular culture, as an embarrassment.
Given its subject, embarrassment may be both inevitable and forgivable. Race, in France as in the United States, is a perpetual source of confusion and discomfort; to address it is always, in some way, to get it wrong. “The Intouchables” sets out to convert that anxiety into easy laughter and also, like “The Help” and “The Blind Side,” to replace antagonism and incomprehension with comfort and consensus. Like those movies, it courts (and deserves) a skeptical response. Yet it also solicits a warm tolerance that it would be churlish to withhold. The film’s brain is hopelessly addled — if you want to see a smart movie about French society, there are plenty of other choices — but its clumsy heart is somehow in the right place.
Positive psychology guru Mihaly Csikszentmihalyi defines his concept of “flow” as a seamless connection between body and mind. Elite athletes call it “being in the zone,” a hyper-focused mental state resulting in streamlined, streaming movements.
“It’s when there is no resistance between work and what you are,” said Adrian Anantawan one morning, as he played a passage from Claude Debussy’s ethereal “Clair de Lune” in the still of Adams House’s Lower Common Room.
For many top musicians, such a feeling often only comes after years of practice. For Anantawan, who was born without a right hand, developing that type of powerful concentration with the violin took extra resolve, a dose of ignorance, and a spatula — a specially designed attachment made of plastic and Velcro that allows him to hold his bow.
After years as a professional musician, the gifted violinist is enrolled in the Arts in Education Program at Harvard’s Graduate School of Education (HGSE), with the goal of helping other disabled students in their artistic and creative development.
“The opportunities,” Anantawan said, “are limitless.”
While investigating the role of adaptive musical instruments in a universally designed music curriculum, Anantawan has connected with scholars at Harvard and beyond, such as music and technology guru Tod Machover, considered the grandfather of “Guitar Hero,” and head of the MIT Media Lab’s Opera of the Future group, and members of the Harvard Medical School community, for lengthy discussions on rehabilitative science.
He has also brought his talent and drive to the classroom, helping students in an inclusive school in Boston with a variety of musical and arts projects.
“If you want to be able to design curriculum or to create new musical instruments for any child, you have to understand how they work … their behavior, their decision-making processes, the interplay between imagination, play, and learning. That’s what fascinates me.”
Anantawan’s own artistic journey began in large part because his parents “didn’t know any better.” Realizing their young son was unable to play the recorder, which requires the use of the fingers on both hands, they quickly sought another musical option.
“We were successful because of that ignorance,” he said. “We came from the premise of ‘why not?’”
With input from Anantawan, a rehabilitation center in his native Toronto helped to create his adaptive device for the violin. The Canadian’s dedication and talent ultimately gained him entrance to Philadelphia’s prestigious Curtis Institute of Music for his bachelor’s degree, and later to Yale University, where he received his master’s degree in music in 2006. His professional career has included performances at the White House, the 2004 Summer Olympics in Athens, and Carnegie Hall. But for Anantawan, something was missing on stage.
“I just felt,” he said, “like there needed to be something more.”
That something more first took shape during a tour of the same rehabilitation center years after it had first helped him as a child. There for a concert, Anantawan was introduced to a virtual device that translates a person’s movement into sound. Intrigued, he sought a grant from Yale and used the funding to assemble a team of psychologists, music therapists, doctors, researchers, and musicians to explore the connections among music, technology, and health care, using the virtual tool. The project culminated in a recent performance given by a former violinist paralyzed from a neurological disorder, and now a quadriplegic, who played with the Montreal Chamber Orchestra.
“Music was such an important part of his life growing up, and to see technology used to give him access to performance once again, but also at such a high level, makes me optimistic of the future for young children with disabilities.”
Inspired by the experience and eager to offer children with disabilities the chance to “communicate their stories to a wide audience,” he turned to the HGSE’s Arts in Education Program. “I realized this was the place I needed to be,” said Anantawan, who sent Harvard his only application. It was Harvard, he said, or nothing.
After graduation, he hopes to teach in a similar inclusive environment where he can work on leveraging the implicit strengths in every child, “regardless of ability.”
For Anantawan, the work is also deeply personal. He recalled being “marginalized” in school for being “slightly different,” and how his world opened when he joined a chamber orchestra at age 12.
“It was one of the first times I was accepted within a peer group, mainly because it’s how you sound; it’s not how you look. It’s how you express and communicate.”
With his future work, he hopes to help children “feel included and be able to express themselves on an equal level with their peers.”
He is well on his way. On his tablet computer, he proudly played a video of his fifth-graders at the Dr. William W. Henderson Inclusion Elementary School performing a dance routine to Michael Jackson’s “Thriller.” A third of the students there have some type of cognitive, behavioral, or physical need. But on stage they were a polished unit, and they were having a blast.
“This is as fulfilling as any concert that I have given in my life,” said a beaming Anantawan. “Carnegie Hall can’t beat these kids.”
The violinist happily admits there are two types of flow in his life now. One involves playing his instrument, the other his work with children.
“I could do this work for hours nonstop,” he said, “and still be happy.”
In his hotel room in New Orleans, Mark Povinelli is reflecting upon the sort of scripts he receives. "They're usually obnoxious. I flick through to what page I'm going to be on and … 'Oh look! Biting someone on the ankle! Or punching someone in the balls!' … The trick is to be one step ahead of them. You can't just say, 'I don't like this', you have to come up with an idea that is better. And that's the real challenge – an extra added task that a lot of average actors don't have to deal with. Not only do you have to be a good performer, but you have to come up with better material than you're given a lot of times, to allow yourself to sleep at night."
Povinelli has appeared in a string of TV shows and films, with his latest project being a main role in Snow White film adaptation, Mirror Mirror. He also happens to have dwarfism, a condition that means he stands 3ft 9in tall. It makes him a member of a specialist industry that is currently in a state of flux. While recognition for it increases, so do threats. It's a livelihood which, in terms of screen work, is sporadic at best, and not always appealing.
The roles open to dwarf actors are, historically, of limited scope. Character-led parts have always been thin on the ground; what opportunities there are, tend largely to be confined to the fantastical — The Wizard of Oz, Star Wars, Willy Wonka and the Chocolate Factory.
There are exceptions, of course: Michael Dunn was Oscar-nominated as best supporting actor for the 1965 romance Ship of Fools, David Rappaport became a credible star on the back of Terry Gilliam's Time Bandits in 1981 ("not even for a lot of money would I be a puppet or a robot," he once said) and, more recently, Peter Dinklage won an Emmy for his portrayal of Tyrion in HBO's Game of Thrones – a role soaked with humanity and depth. Even so, a limited range of roles is a frustration for any actor who wants to be taken seriously.
Yet dwarf actors also face a fight for their traditional roles on the most apt of battlefields: Snow White. Two separate adaptations are released this year: one of them (Mirror Mirror, in which Povinelli plays a character called Half Pint) uses a full cast of dwarf actors; while the other, Snow White and the Huntsman, replaces them with well-known names such as Ian McShane and Nick Frost shrunk using CGI.
Such a practice is hardly new, of course: Lord of the Rings famously used camera angles to resize its actors, as will dwarf-heavy prequel, The Hobbit, released later this year. Just as dwarf actors' work is being threatened in pantomimes by child actors, such FX trickery is eradicating roles traditionally held by dwarves. It's a novelty that isn't going down well.
"What it ultimately comes down to is that this is a business," Povinelli says. "And the driving force for making the [Snow White and the Huntsman] decision was to get names that would hopefully sell the film. I don't agree with it, of course."
"I mean, I've got no problem with Ian McShane playing a dwarf, if I'm allowed to play a lawyer or a doctor or all of the things we seem to be denied so often. I don't want the market on the fantastical characters – that doesn't interest me. I want the whole range. I don't begrudge McShane taking on that role but the coin should be flipped as well and we should be allowed to play actual humans. Because … you know, it's pretty obvious but that's what we are. I'm not a leprechaun. I'm not an elf. I don't live in a forest. I'm a dad, I'm a husband, I'm a sports fan, I'm a theatregoer ... I'm everything everyone else is. And those are the things you want to portray."
Danny Woodburn, an established TV and film actor best known for his roles in Seinfeld and Watchmen, also plays one of the seven dwarves in Mirror Mirror. He agrees with Povinelli. "To me, that's still telling of the nonacceptance of dwarfism ... You would never see this with any other minority — it isn't acceptable. In today's industry, you would never see someone seriously playing an African American who wasn't an African American. Yet it is acceptable in the realm of actors portraying people with dwarfism, or disabilities in general."
Woodburn is a member of the Screen Actors Guild for Performers with Disabilities Committee, and is outspoken when it comes to dwarfism issues – especially the sneery sense of schadenfreude and dehumanisation that they're occasionally subjected to. "I have put it in my contract before that no one will pick me up in a scene, and I will not be required to bite anybody" he says. "Do you not see how humiliating it is to liken me to some kind of animal?"
It's for this reason that Woodburn is surprised by the fuss surrounding Warwick Davis's Life's Too Short – the TV show that has triggered much debate about dwarf actors. "It's amazing that people are so shocked and in uproar about this, when I've seen the exact same sort of treatment in a realistic way. No one goes crazy about that."
The reactions to Life's Too Short just go to show the variety of opinions on how dwarves should be seen on screen. Yet between the protection of traditional roles and the hunger for meatier ones, the consensus seems to be that what the dwarf acting industry needs is the chance for louder voices – something that was basically nonexistent in the days where Kenny Baker walked into the role of R2-D2.
Willow Management, a dwarf acting agency based in the UK, looks after almost 250 clients across the world. Their role, according to Peter Burroughs, who runs the agency with Warwick Davis, is to look after the interests of dwarf actors, put them forward for auditions and to "step in if our clients feel like they're being exploited".
Despite a relatively large number of actors on their books (although minuscule in the context of the acting industry as a whole), Burroughs says very few actually approach it as a serious, full-time career. He thinks it might be an issue of confidence, but is certain that's changing.
"We put them forward for auditions and try to help them out so they'll pass them," he says. "We do acting lessons to give them confidence, and to be able to assert themselves as actors. We also try to make the industry aware that these people are capable of doing a good acting job. After all: as long as there's good actors, the industry will survive."
But what needs to change so that dwarf actors have the chance to showcase their talent? Woodburn singles out one of the biggest problems: a lack of understanding from writers. "A path writers go down is the pathos of smallness, where the person with dwarfism is pathetic because of their size ... A writer will say, 'Oh, you're a sad little man'; but the reality is, 'No, I'm not a sad little man, I'm just kinda pissed off because society won't accept me as a man.' If I'm going to be seen as a dwarf, then I want to be seen as the dwarf I know I am – not the one the writer has made up in their mind having no experience of people with dwarfism."
Povinelli agrees; he is also optimistic for a future that is led by actors such as Dinklage. "The opportunity still needs to meet the talent level, but the glass ceiling is starting to shatter."
"Hopefully we're evolving as a society so that we're coming to the realisation that people with a difference can actually offer something with a unique perspective rather than being something of wonder or something to be laughed at. And I think that's coinciding with the fact that there's a real pool of super-talented actors who are finally getting a chance to show what they can do – to finally be seen as actors first, and dwarves second."
Mirror Mirror is out now. Snow White and the Huntsman is released 1 June.
In January, the actor Peter Dinklage surprised himself during his own Golden Globe acceptance speech. Dinklage had won the award for best supporting actor in a TV series for his portrayal of the complex, sharp-tongued Tyrion Lannister, who’s the closest thing to a hero in HBO’s epic swords-and-sex hit “Game of Thrones,” which returns for its second season on April 1. As he took the statue from the presenter, Piper Perabo, the onstage microphone stand quietly lowered into the floor to accommodate the 4-foot-5 actor.
Dinklage thanked the people he needed to thank — the author George R. R. Martin, who wrote the novels on which “Game of Thrones” is based; his mother in New Jersey; the cast and crew. As the wrap-it-up music began to swell, Dinklage thought about what his wife had been telling him all night at their table: “Let people know. It isn’t right.” He hesitated a moment, then thought, I’m just gonna do it. “I want to mention a gentleman I’ve been thinking about, in England,” he said quickly. “His name is Martin Henderson. Google him.”
A month later, during breakfast at the Trump SoHo hotel in Manhattan, Dinklage still seemed a bit uncomfortable with the attention his off-the-cuff comment received. “I read about him online the day before the Globes. It really made me sad. I don’t know why.” He corrected himself: “I mean, I know why: it’s terrible.” In October, Henderson, who is 37 and is 4-foot-2, was picked up and thrown by an unknown assailant in Somerset, England. He suffered partial paralysis and now requires a walker. The night of the Globes, after Dinklage’s mention, Henderson’s name was a trending topic on Twitter. Dinklage later turned down offers to discuss the case with Anderson Cooper and other news hosts.
“People are all, like, I dedicated it to him,” he said. “They’ve made it more romantic than it actually was. I just wanted to go, ‘This is screwed up.’ Dwarves are still the butt of jokes. It’s one of the last bastions of acceptable prejudice. Not just by people who’ve had too much to drink in England and want to throw a person. But by media, everything.” He sipped his coffee and pointed out that media portrayal is, in part, the fault of actors who are dwarves.“You can say no. You can not be the object of ridicule.”
In many ways, Dinklage’s own story is unsurprising: an actor who flailed for years, worked steadily for some more years, then got a great role and became famous. The part of Tyrion Lannister has now won Dinklage that Globe, an Emmy and an army of new fans who never saw him in “Living in Oblivion,” onstage in “Richard III” or even in his breakout film, “The Station Agent,” in 2003.
Yet Dinklage’s sudden stardom offers a pleasurable meritocratic twist to his career, given that the entertainment industry doesn’t typically reward those who turn down roles on principle, much less actors who don’t meet a certain physical ideal. Sure, James Gandolfini struggled before “The Sopranos” made him an unlikely leading man. But James Gandolfini didn’t eat potato chips for dinner every night because he conscientiously objected to playing one of Santa’s elves in Kmart ads.
Dinklage recently moved away from New York, the city he called home for most of the past 20 years — first in Williamsburg and then in the West Village. The city was making him feel older than his 42 years. “Just all the clawing for space,” he said. “I felt myself becoming a bitter old man in New York, and I wanted to avoid that.”
So he has settled into a house in the woods in upstate New York with his wife, the theater director Erica Schmidt, and their baby daughter. But just 10 days after moving, Dinklage was back in Brooklyn, playing a “bitchy barista” in “A Case of You,” a small-budget romantic comedy written by his friend, the actor (and “I’m a Mac” pitchman) Justin Long. “This is the first time,” Dinklage marveled, “I’ve ever stayed in a hotel in New York.” Why come back to the city so soon for a small role in an indie film? It’s simple, he said. “When our friends call us to be in their movies, we show up.”
Dinklage grew up in Brookside, N.J., an hour west of the Lincoln Tunnel, and his insurance-salesman father and music-teacher mother didn’t even have a TV set in the house — or so Dinklage and his brother thought. One night when Dinklage was in his teens, he heard odd sounds coming from his parents’ bedroom and opened the door to find them watching a black-and-white TV they had just bought and hid in the closet. “So,” he recalled delightedly, “it was ‘Three’s Company’ from then on out, and my brain started to melt.”
Both Dinklage and his brother, Jonathan, were natural performers. (Jonathan now works as a professional violinist.) While Dinklage has said that as the only dwarf in his family, he was often angry about his height in his youth, he is quick to credit his parents for a relatively happy childhood. “I was fortunate enough,” he said, “to have an upbringing that made me more accepting of who I am.” After studying acting at Bennington, he moved to New York in 1991 with his friend and classmate Ian Bell, with visions of building a theater company modeled on the famous Steppenwolf in Chicago. Dinklage points to the 1984 “American Playhouse” production of Sam Shepard’s “True West,” starring Gary Sinise and John Malkovich, as the moment that steered him toward a career in acting. “A lot of us became actors because of that. Men my age — that was the linchpin.”
The apartment they shared under the Williamsburg Bridge had no heat and shook when trains passed overhead; the oven was unusable, because it was filled with rats. When they complained, Dinklage recalled, the landlord pulled a knife in the living room. “It wasn’t really a living room,” Dinklage said, “just a big empty space that we dreamed of doing ‘True West’ in. But we ended up drinking too much and had one poetry reading.” Bell recalls it “as a space where we could have parties to raise the money to make rent,” but eventually they couldn’t make the rent — they came back from the holidays one year to find the door bolted shut.
Bell left for Seattle, where he’s now an actor and a director. Dinklage stayed in New York and soon was landing stage work and the occasional low-budget film. But he couldn’t book commercial jobs, because he wasn’t interested in the kinds of roles that paid well for dwarves. Specifically, he wouldn’t play elves or leprechauns. Even after Dinklage’s memorable first film role in the 1995 Steve Buscemi indie comedy “Living in Oblivion” — Dinklage played an actor who’s annoyed to be cast in a dream sequence, demanding, “Have you ever had a dream with a dwarf in it?” — he still couldn’t get an agent. “Word got out,” he says. “I started to build up a resentment. And that fueled my desire to live in a cold apartment and be like: ‘I don’t need you! I’m gonna write poetry. Why would I want to be a member of your club if you don’t want me?’ ”
After a recommendation from Buscemi, the New York-based film director Alexandre Rockwell cast Dinklage in his shaggy-dog ensemble comedy “13 Moons.” When Rockwell met Dinklage just before his first day of shooting, they were instantly simpatico. “You might come in with some luggage about Peter’s physicality,” Rockwell says. “Right away he cuts right through that. You’re thinking, He’s a dwarf, he’s a dwarf, but Peter comes shining through as a personality beyond any kind of diminutive-size issue.”
“Alex attracts Steve Buscemi and Seymour Cassell and all those actors that are in his movies,” Dinklage said, then added with pride, “I’m one of them.” By the end of the ’90s, Dinklage was managing to make a meager living. “What I really want,” he told a theater Web site in an interview, “is to play the romantic lead and get the girl.”
Then Tom McCarthy, a recent Yale grad, met Dinklage when the actor portrayed Tom Thumb in a vaudevillian play McCarthy directed and co-wrote. The two became friends, and McCarthy was soon convinced that, indeed, Dinklage was leading-man material. “It was crystal clear,” McCarthy says. “There are qualities that leading men possess, this kind of self-assuredness and this vulnerability. Pete had both.” One day McCarthy and Dinklage ran into each other on a Manhattan street corner — “Peter was temping, and I was just scraping by as an actor” — and McCarthy later thought that Dinklage might be perfect for a script he was working on, “The Station Agent,” about an introverted train aficionado who inherits a tiny depot building in rural New Jersey. “We never imagined,” McCarthy says, “that conversation would alter both of our careers.”
Soon McCarthy had rewritten the character for Dinklage. Along with Bobby Cannavale and Patricia Clarkson, two other New York theater veterans for whom McCarthy had written roles, Dinklage showed up for reading after reading while McCarthy honed the script and raised a half-million dollars. “He never wanted to do it with anyone but us,” Dinklage said. “That sort of loyalty is really rare.” In 2003, “The Station Agent” won the Audience Award at Sundance and kick-started the careers of both its director and its star.
“I’d been in great films before, but I’d never been involved in something from the early stages,” Dinklage said. “It’s the way I wanted to work. Like Steppenwolf — loyal to the ensemble.” Dinklage views loyalty as a superior character trait; he has a circle of close friends, from Bennington and the New York film and theater scenes, who have stuck together for years. Artistic endeavors, he believes, foster the kind of foxhole friendships that last forever — relationships that last because people don’t “follow that distracting white balloon of money or somebody more famous.”
“The base line of our friendship is: He gets the joke,” says Jonathan Marc Sherman, a playwright who attended Bennington with Dinklage. In the early years, when they all were having trouble finding work they felt proud to do, every November brought a wave of calls from casting directors with elf roles. “Having the group of friends helps you stick to what your instincts are telling you to do,” Sherman speculates — though, he notes for the record, “If they’d offered me those elf roles, I would’ve taken them in a second.”
Ten years after “13 Moons” and just before Dinklage was cast in “Game of Thrones,” he offered to help produce Rockwell’s next film. “With whatever clout I had,” Dinklage said, “I wanted to see what I could do to sort of protect him.” The movie was called “Pete Smalls Is Dead.” “It came and went,” he said. “Of course nobody saw it, but that’s O.K.” The opening credits for “Pete Smalls Is Dead” list 14 producers, including Dinklage. “Out of those 14,” Rockwell says, “I could have traded eight for Peter.” He laughs: “ ‘Producer’ is such a joke. I still have never met three or four of them. But Peter was on the front line.”
“It’s funny, loyalty,” Dinklage said at the restaurant. “I’ve never really thought about that. Friends of mine will read this and say, ‘Ah, it’s important in us, but it’s not important in him.’ I’m wondering if I’m loyal now. I think I am.” He stared down at his plate. “I should call people back more readily. I’m not the best friend sometimes in terms of that. I do follow that white balloon and get distracted a lot.”
I was curious how far Dinklage’s loyalty extended, so I asked him about the weirdest, most inexplicable title in his filmography: “Tiptoes.” “ ‘Tiptoes’!” he exclaimed, shaking his head. “Oh, that movie. That was something.”
“Tiptoes” stars Kate Beckinsale and Matthew McConaughey as a couple whose relationship runs into trouble when she learns that his entire family are dwarves. As she struggles with the fact that the baby she’s carrying may also be differently sized, she is reassured by her brother-in-law, played not by Dinklage (he plays a friend) but by Gary Oldman in, according to the trailer, “the role of a lifetime” — on his knees, with a harness to shorten his arms and a hump under his shirt. Gary Oldman, that is, plays a dwarf. “There was some flak,” Dinklage acknowledged. “ ‘Why would you put Gary Oldman on his knees? That’s almost like blackface.’ And I have my own opinions about political correctness, but I was just like: ‘It’s Gary Oldman. He can do whatever he wants, and I’m so happy to be here.’ ”
I told him I was impressed that he would defend “Tiptoes,” a movie that seems, on its face, ridiculous. “It was a lovely mess of a movie while we were making it,” he sighed. “I saw the director’s cut, and it was gorgeous.” That two-and-a-half-hour director’s cut was shown at a film festival in Austin, Tex.; the director, Matthew Bright, was reportedly fired shortly afterward, and the movie was recut. “The people who fired him ruined the movie,” Dinklage insisted. “They made it into a weird little quirky rom-com, but with dwarves.” He looked gloomy as he recalled this. “It was sort of an amazing idea for a movie, but the result was what we were fighting against — the cutesiness of little people.” I asked if he ever hoped to be a spokesman for the rights of little people. He made an exasperated sound and held his hands out, palms up. “I don’t know what I would say. It would be arrogant to assume that I. . . .” He put his hands down on the table. “Everyone’s different. Every person my size has a different life, a different history. Different ways of dealing with it. Just because I’m seemingly O.K. with it, I can’t preach how to be O.K. with it. I don’t think I still am O.K. with it. There’s days when I’m not.”
The final day of the “Case of You” shoot, a man approached Dinklage looking for an autograph. “He had this ‘Game of Thrones’ coaster,” Dinklage recalled. “With me on it! And it was legitimate. It wasn’t like he made it in a copy shop. That was bizarre. Do you just walk around with a Formica coaster?”
For all the wild fandom it provokes, “Game of Thrones” started out like all those other gigs over the years: as a call from a friend of a friend. “I knew David Benioff a bit socially,” he said. “I knew his wife, Amanda Peet. He’s a smart guy, so I always sought him out at dinner parties.”
“He was always much friendlier to Amanda than he was to me,” Benioff says. “I knew he was incredibly funny, incredibly smart and had that caustic wit.” From the beginning, Dinklage was the first choice for the role of Tyrion, according to Benioff and the show’s co-creator, Dan Weiss, who observes that Dinklage’s “core of humanity, covered by a shell of sardonic dry wit, is pretty well in keeping with the character.”
Dinklage was cautious during his first “Game of Thrones” meeting. In the film “Prince Caspian,” part of the “Chronicles of Narnia” series, he had played the dwarf Trumpkin and spent the seven-month shoot in Eastern Europe and New Zealand sweating under a long red beard. “It was a lovely experience,” he said diplomatically, “but it was pretty uncomfortable.” So in that meeting with Benioff and Weiss, before anyone explained “Game of Thrones” or Tyrion Lannister to him, he made a simple request: no beard, no pointy shoes. “Dwarves in these genres always have this look. My guard was up. Not even my guard — my metal fence, my barbed wire was up. Even ‘Lord of the Rings’ had dwarf-tossing jokes in it. It’s like, Really?” But he learned from Benioff and Weiss that Tyrion was a different kind of fantasy little person. “He’s somebody who turns that on its head. No beard, no pointy shoes, a romantic, real human being.” And perhaps most important in getting Dinklage, who still hadn’t had that many lead roles in the years since “The Station Agent,” to sign on before the meeting was half over: “They told me how popular he was.”
Indeed for fans of the novels, Tyrion is among the most beloved among the scores of kings, warriors, wenches, slaves, queens and monsters that populate George R. R. Martin’s world. “My readers identify with the outcast,” Martin says, “with the underdog, with the person who’s struggling rather than the golden boy.” But Dinklage’s sly performance has made Tyrion all the more popular. He plays Tyrion as the only modern man in a muddy, violent, primal world. He loves good food, good conversation and a good book. Unlike the warmongering lords and knights of Westeros, but like most HBO subscribers, he would prefer to stay out of battle; when he’s forced by his father into leading a regiment to war, he manages to be knocked unconscious before the fight even begins.
Certainly Tyrion gets many of the series’ funniest lines. “How would you like to die?” a fearsome warrior asks him in the show’s first season, waving an ax. “In my own bed, at the age of 80, with a belly full of wine” and attended by a woman, Tyrion answers. But Dinklage’s bravado masks Tyrion’s deep well of melancholy; the black sheep of a powerful family, he has been despised his whole life by his iron-willed father and hot-tempered sister, Cersei. In the second season, Tyrion is cast in the unfamiliar role of power broker in the nation’s capital, sent to rein in the excesses of Cersei, now the queen. “It must be odd for you,” Tyrion tells Cersei in one of the first new episodes, “to be the disappointing child.” Dinklage delivers the line not with a cruel, mocking flourish but with a hint of sadness — at the only way he can connect with the sister who never loved him.
Recently Dinklage had to confess to Martin that he had read only the first book in the “Game of Thrones” series. “He looked a little hurt,” Dinklage said. “I felt bad. But no disrespect, I still haven’t read all of Tolstoy.” Dinklage likes being surprised when the scripts come in; when I asked if he really didn’t know all the crazy things that will happen to Tyrion in coming seasons, he shrugged. “I need to know the back story, obviously, to figure out who this guy is. But the . . . front story? Is that even a word?”
The series, which famously killed off the heroic Ned Stark at the end of its first season, is no safe place for an actor. “It is amazing how many more people die,” Dinklage said. “Like, leads. Like, coming up. People are gonna be shocked. They think Ned Stark was something — there’s so many more.” Tyrion, for what it’s worth, seems unkillable. “There’s a lot ahead of Tyrion,” Martin says, and judging from the books, that’s true — so far. Dinklage said he was signed on for six seasons — further into the future, possibly, than anyone besides Martin can see. “Anyways,” Dinklage said, “HBO will read this and laugh, because they own my life. ‘Ha ha ha, he signed that in blood!’ ”
The success of “Game of Thrones” — the show was renewed for a second season within days of its premiere, its viewership increased throughout the season and it was nominated for 13 Emmys — has led Dinklage to attend fan events of the sort he’s never done before. He finds it hard, sometimes, to put himself out in the world after a lifetime spent encircled by his own little Steppenwolves. His rambunctious, witty character helps, and so in a way, he’s acting, even offscreen. “They’re somewhat expecting Tyrion, you know? I mean, they like me, but they just kind of want me to say my favorite lines and stuff.” He laughed. “He’s a great character to hide behind. He’s a large personality.”
During his hiatus from “Thrones,” Dinklage hopes to act in Molière this summer at Bard, under his wife’s direction. He has been developing a script for years, based on the life of the “Fantasy Island” star Hervé Villechaize, with his friend Sacha Gervasi, director of “Anvil!” “He interviewed Hervé right before he killed himself. Sacha was a journalist, sitting here like we are now. After he killed himself, Sacha realized Hervé’s interview was a suicide note.”
What else? “My friend Mark Palansky wrote this amazing script for myself and Catherine O’Hara,” he added, which spun into a discussion of O’Hara’s greatest moments in Christopher Guest mockumentaries. “That’s a true company of loyal people,” he sighed. “They have a home, don’t they?” Do you ever wonder, I asked, how you could get in on that? He brightens. “Maybe working with Catherine will help!”
He hasn’t quite found his own home yet, but maybe his six or seven or eight or nine years on “Game of Thrones” will provide him one. Or maybe the communities he’s building around himself will keep growing until they encompass all New York and Hollywood.
“I feel really lucky,” he said, then added, “although I hate that word — ‘lucky.’ ” When I asked him why, he mulled it over for a moment, looking away. Then he focused back on me. “It cheapens a lot of hard work,” he said. “Living in Brooklyn in an apartment without any heat and paying for dinner at the bodega with dimes — I don’t think I felt myself lucky back then. Doing plays for 50 bucks and trying to be true to myself as an” — here he put on a faux snooty voice — “artist and turning down commercials where they wanted a leprechaun. Saying I was lucky negates the hard work I put in and spits on that guy who’s freezing his ass off back in Brooklyn. So I won’t say I’m lucky. I’m fortunate enough to find or attract very talented people. For some reason I found them, and they found me.”
Williams announced her withdrawal from the tournament Wednesday after being diagnosed with Sjogren's syndrome -- a condition in which the body's immune system attacks its own healthy tissues. Williams said she has struggled for years with symptoms that she now knows are linked to the condition.
"I think I've had issues with Sjogren's for a while. It just wasn't diagnosed," Williams said. "The good news for me is now I know what's happening."
While a combination of genetic and environmental factors can lead to Sjogren's, the condition is often triggered by an infection. The symptoms vary, but almost always include dryness in the mouth and eyes. Joint and muscle inflammation and fatigue can also occur.
"I had trouble with stamina," Williams said, adding that her doctor diagnosed her with exercise-induced asthma four years ago. But it wasn't until this summer, when she developed more definite symptoms, that an accurate diagnosis was made.
"I had swelling and numbness and fatigue, which was really debilitating. I just didn't have any energy," Williams said. "And it's not that you don't have energy; you just feel beat up."
Deciding to drop out of the U.S. Open wasn't easy, Williams said.
"… I just felt like, 'Okay, I could walk out on the court. I'm a tough woman, I'm a tough athlete, I've played through a lot of things.' But what kind of match it would be?" she said. "It was a tough decision, but at the same time I've had to come to accept what I'm going through."
Williams said she's glad to finally have an explanation for her mysterious, debilitating symptoms.
"It's a huge relief because as an athlete everything is physical for me -- everything is being fit and being in shape," she said. "I think the best thing that could have happened for me this summer was to feel worse so I could feel better."
While Sjogren's has no cure, there are treatments that make symptoms more manageable: Artificial tears and saliva stimulants can ease dryness; anti-inflammatory drugs can reduce joint and muscle inflammation; and certain drugs can help quell the overactive immune response.
"Sjogren's is something you live with your whole life," Williams said. "The good news for me is now I know what's happening after spending years not knowing... I feel like I can get better and move on."
Williams said she "absolutely" plans to return to tennis.
"Serena's conditions helped me to feel a new life on life in itself," Williams said. "So this, right now, I think will help me to feel grateful for everything that I have. And at the same time it makes me want to get up and fight harder every single day."
Although this talk was presented in a workshop on rheumatoid arthritis, its message applies to people with many types of systemic rheumatic disease, including lupus (SLE), fibromyalgia, scleroderma, and others.
Most people think of arthritis as just pain, stiffness, and achiness in one or more joints and having difficulty with activity related to those joints, because that's what osteoarthritis (the most common type of arthritis) is all about. It's a localized condition in the joints.
But there are more than 100 different forms of arthritis, and rheumatoid arthritis (RA) is the most common form of systemic arthritis. Systemic means it's not localized but affects your entire body. Although the most common symptoms of RA are joint pain, swelling, stiffness, warmth, and redness, there are many other things going on in the body that cause you not to feel well - and to suffer with fatigue.
What is fatigue in rheumatoid arthritis?
It's easier for people to think of joints as causing problems than to think of fatigue and the other intangible things that give RA patients trouble. That's because fatigue is not something you can put your finger on. It's a sense that you're not feeling up to par, that you're slowing down. Nothing else may be wrong that's obvious to you or your physician. You may or may not have joint pain or stiffness at that moment. But the fatigue is there.
Patients sometimes compare the fatigue of RA to recuperating from the flu - as if they're trying to keep up and can't do it. But that's not quite all of it. There's something more that's hard to define. The fatigue of having a systemic rheumatic disease is unique and can be very difficult for patients and those around them.
When people ask, "How are you?" and you say, "I'm fatigued," they ask, "What do you mean?" Well, it's not just being tired or feeling that you want to sit still. It's something deep inside that's slowing you down - maybe slowing your thinking or initiative. It's something telling you that you don't feel quite right.
Can RA fatigue be measured?
So far, no. It's an intangible symptom that, despite great effort, physicians have been unable to define nor directly measure. But we can indirectly measure it by its impact on daily activities and state of mind, which varies from patient to patient - and changes for any one patient over time. But enough people have complained about fatigue over time that we know - and you know - it's real and its impact is profound.
Why might RA patients have this fatigue?
Consider the rheumatoid factor and other antibodies found in people with RA. Those are not just found in joints. They are found in blood throughout your body. That's an indicator that something is awry throughout the body.
Why is fatigue so difficult to cope with?
It might be easier to have a disabling condition that happens and then is stable; it stays the same, and you develop coping mechanisms to deal with it because you know what to expect and people around you know what to expect.
But that's not the way RA works. Big fluctuations occur randomly. One day you feel fantastic and can do everything you and others expect of you. The next day you can't even get out of bed. And every time that happens, you have to reestablish your coping mechanisms - both functional (who will prepare the meals, take care of the family, etc.) and psychological (how do I get through this with my feelings intact).
It's often easier to get through those fluctuations when you can pinpoint the problem - "These knees are swollen and painful" - than when the problem is as intangible as fatigue, which can occur in the absence of physical symptoms. Fatigue can be "hard to believe," especially when you've been feeling so well just before it hits. So, all too often, because you can't "see" it, you belittle fatigue. "Is it that I did too much yesterday or didn't get enough sleep last night, or is it my disease acting up again? And if it is my disease, do I really want to acknowledge that? Can I ignore it, push it aside and just keep going?" And that's exactly what you sometimes do - push it aside in order to feel like the person you were before you got this disease. Acknowledging the fatigue, and responding to this intangible sign of disease, is difficult - but essential.
How can you master fatigue?
The key to living successfully with the fatigue of RA is developing strategies - physical/functional coping strategies, as well as psychological coping strategies.
You have to acknowledge that fatigue exists and that it's something you can't necessarily control or predict. If you have to take time off just to feel better, that's okay - because anyone else experiencing this type of disease would expect to be allowed to do the same thing. So you have to allow yourself to feel this way. There's nothing wrong with saying that fatigue is having an impact on you - that even though you are not in pain, your disease is still dragging you down and you're not feeling well.
You have to acknowledge that fatigue won't necessarily be easily understood by people around you, because you don't have obvious physical symptoms. When it's "just" fatigue, it's tough for others to understand, and you may not even want to tell them. You may fear that they will think you're lazy because they don't see anything wrong with you. You have to be prepared for responses like, "I'm tired too." And you need to think about and decide what your own level of comfort is in responding to such comments - whether or not you want to share with them the details of your systemic disease and why your fatigue is so different from their tiredness.
You have to remember that fatigue creates a feedback loop: when you're fatigued and can't keep up, you may get frustrated and angry, especially if you don't acknowledge your fatigue. So people around you may respond both to your physical slowness and - or - your emotional reactions to your fatigue. That's one of the ways your fatigue may cause problems with social and work relationships. And those problems may include very close family members who supposedly know what RA is and what it means. Indeed, conflicts may be more apt to arise when you don't give in to fatigue and admit that you don't feel well. So it may be better to be open with yourself and those around you and simply say, "I have to bow out of this social engagement" or "I can only stay for a limited period of time" because "It's important that I rest and take care of myself."
You have to learn to find balance and compromise, which may lead to opportunities you had not considered. The art of mastery for living with a chronic disease is compromise. But it's important to remember that you are not alone in that, although your challenges are greater. Life involves compromise for everyone. Fatigue is one of the many things that you have to allow for as we seek balance, whether that's with work, school, or social relationships. Here are some important ways we can find balance and compromise.
Adapt to your situation with appropriate changes. If fatigue is having too much of an impact on our work, we may have to change jobs or take time off. But if it's what you really want to do, you can often find ways around it. I've never met anyone who would say that the life they are living is the one they might have envisioned for themselves 10 or 20 years ago. If your RA is such that you can no longer figure skate, well, you can find new interests. There are always ways to adapt. Remember the old saying about "When life gives you lemons, make lemonade." Sometimes fatigue can even bring rewards when you search out new opportunities and learn to find joy in new things that you would have not have considered doing in the absence of RA - whether that's in your career or in hobbies.
Give in to fatigue when necessary - so you can spring back. The only way you're going to be able to work and continue to be a productive member of society is to give in to fatigue. By giving in, I don't mean giving in to the disease. I mean periodically giving in to the fatigue - to rest and do whatever is necessary so that you can improve as quickly as possible and get back to your life and doing the other things that you enjoy. That's part of finding the balance, because one aspect of dealing with fatigue is maintaining your normal lifestyle in between the periods when you have fatigue.
Work with your doctor to assure balance in medication benefits and side effects. Some of the medications you take (especially steroids) can cause a host of side effects, and fatigue is one of them. So both the disease and your drugs can affect your lives. It's important to maximize the benefits of your medications while minimizing their side effects. That's why, for example, folic acid is often prescribed for people taking methotrexate. This is a juggling act that you have to work out with your physician.
Get enough sleep. Sleep disorders are very common among people with RA and other systemic rheumatic diseases, such as lupus. Often, sleep problems are due to discomfort or to medications such as steroids. Sometimes taking a drug to help induce sleep will improve fatigue and your overall sense of well-being.
Get help with depression. Are you depressed because you feel fatigued, or are you fatigued because you feel depressed? Or is it the whole gestalt of living with this unpredictable disease and the adjustments it requires? Don't get caught in this catch-22. Discuss it with your doctor. Sometimes, a low-dose antidepressant, given at night, can help sleep, ease the discomfort of fibromyalgia-like symptoms, break the vicious cycle, and have a positive impact on your sense of well-being.
Exercise is essential. Keeping your muscles conditioned makes every activity easier and less tiring. And the endorphins generated by vigorous exercise - even brisk walking or, even better, exercise with light weights - can help reduce fatigue. Even when you feel awful, go through range of motion exercises every day. Don't do impact exercise when joints are inflamed, but continue with range of motion exercise. You can even do exercise while sitting in a chair. Exercise is something proactive that you can do without someone else's help - to help yourself feel better physically and psychologically.
Set up your home to make life easy for you. Start in the kitchen, keeping everything your use often within easy reach. Then do the same in your bathroom and bedroom. This may require major reorganizing. Don't set up for when you feel good; set up for the difficult times.
Establish a work schedule that works for you. If you have morning stiffness, maybe it's better to start work later. You don't have to be like everybody else because there's no such thing as "everybody else" anymore. With computers and faxes, you can have a full-time job at home and only go to the office for special meetings. Today, you can tailor your work to your life - and you won't be alone in doing it.
When traveling, plan ahead and anticipate. Travel can be tiring for anyone; when you have RA, it can be worse. If you're crossing time zones, ask your doctor and plan how you will have to change your medication schedule. Take a pillow for your neck to avoid stiffness. Know what little things will make it easier for you, whether that's a cold pack or a hot pack to toss in the airplane's microwave, so your RA won't have as much of an impact on you when you get to your destination.
An international team of scientists has identified 29 new genetic variants linked to multiple sclerosis, providing key insights into the biology of an important and debilitating neurological disease.
Multiple sclerosis, one of the most common neurological conditions among young adults, affects around 2.5 million individuals worldwide. It is a chronic disease that attacks the central nervous system, which includes the brain, spinal cord and optic nerves, and can cause severe symptoms such as paralysis or loss of vision.
“We now know just how complex multiple sclerosis is,” said Jonathan Haines, director of the CHGR and one of the principal researchers in this effort. “These new genes give us many new clues as to what is happening in MS and will guide our research efforts for years to come.”
Researchers studied the DNA from 9,772 individuals with multiple sclerosis and 17,376 unrelated healthy controls. They were able to confirm 23 previously known genetic associations and identified a further 29 new genetic variants (and an additional five that are strongly suspected) conferring susceptibility to the disease.
Many genes implicated in the study are relevant to the immune system, shedding light onto the immunological pathways that underlie the development of multiple sclerosis.
One-third of the genes identified in the study have previously been implicated in playing a role in other autoimmune diseases such as Crohn’s Disease and Type 1 diabetes, Haines said.
Previous studies have also suggested a link between vitamin D deficiency and an increased risk of multiple sclerosis; researchers in this study identified two genes involved in the metabolism of vitamin D, providing additional insight into a possible link between genetic and environmental risk factors.
"Good throw. He does have a good throw," said seven year old Indy Pinney's parents as they watched him toss a frisbee.
They are especially proud of that throw, and his running, even when his dog Sandy wins the frisbee game. It's a remarkable change from his life three years ago.
"He did not want to run. He did not want to have to walk fast. He complained that it hurt," recalled his mother Shawna Pinney.
At first Indy's symptoms confused his parents and his pediatrician.
"His knees were unusually large. But he was also very skinny," said Pinney.
It wasn't until months later, that Indy was diagnosed at Seattle Children's. He had severe juvenile arthritis. The disease inflames joints, and destroys bone, crippling young victims. It was all through his body.
"Forty seven joints that were active with arthritis," said Pinney.
She said juvenile arthritis is hard to diagnose in kids because it mimics other conditions.
"They're limping, they have a swollen joint. Maybe they have joint pain. They could also present with high spiking fevers and rash," explained Dr. Wallace.
She led a national study in hopes children like Indy would benefit from early aggressive treatment. Researchers compared combinations of methotrexate, Enbrel, and prednisone. Though not perfect, the treatments proved promising for kids.
"You can actually get them to a state of completely inactive disease by six months. And we were very pleased that we were able to do that in over a third of the children. It was just very exciting," said Dr. Wallace.
The children must be carefully monitored because the drugs have potential negative health consequences, including risk of cancer. But juvenile arthritis can cripple a child.
"And how do you balance the potential for some rare side effect ten years down the road twenty years down the road versus getting destroyed joints in the next five to ten years?" Dr. Wallace explained the dilemma of families.
For Indy's parents it came down to this.
"We wanted him to be better. We wanted him to experience a normal childhood," said Shawna Pinney.
Now, with his medications, that normal childhood is within reach for Indy.
The researchers have started a national registry to track children on all arthritis medications. They hope the registry will yield answers that improve care in the future.
Arthritis is a large and growing pu , and 65.4% in 2009.§ Respondents were defined as having doctor-diagnosed arthritis if they answered "yes" to "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" Those who responded "yes" to having doctor-diagnosed arthritis were asked "Are you limited in any way in any of your usual activities because of arthritis or joint symptoms?" Those responding "yes" to both questions were categorized as having AAAL.
Statistical software was used to account for complex multistage sampling design and produce weighted estimates and 95% confidence intervals. Unadjusted prevalence was estimated to describe the actual population burden; age-adjusted prevalence, standardized to the 2000 U.S. standard population, was estimated to facilitate comparisons among demographic subgroups. For all comparisons, statistical significance was determined using a two-sided t-test; differences were considered statistically significant at p<0.05.
During 2007--2009, an estimated 22.2% (49.9 million) of U.S. adults reported doctor-diagnosed arthritis. Arthritis prevalence increased significantly with age. After adjustment for age, arthritis prevalence was significantly higher among women (24.3%) than among men (18.2%); those with less than a high school diploma (21.9%), compared with those with at least some college (20.5%); persons who are obese (29.6%), compared with normal/underweight (16.9%) and overweight (19.8% ); physically inactive persons (23.5%) versus those meeting physical activity recommendations (18.7%); and current (23.7%) or former (25.4%) smokers, compared with never smokers (19.0%)
During 2007--2009, an estimated 9.4% (21.1 million) of U.S. adults reported AAAL. After adjustment for age, patterns of prevalence of AAAL were similar to those for doctor-diagnosed arthritis.
Among adults reporting doctor-diagnosed arthritis, the unadjusted prevalence of AAAL was 42.4%. After adjustment for age, the greatest prevalences were among persons categorized as obese class III (52.9%), those with less than a high school diploma (52.0%), physically inactive persons (51.2%), current smokers (47.6%), those categorized as obese class II (46.7%), and non-Hispanic blacks (45.5%)
Among both men and women, age-adjusted arthritis prevalence increased significantly with increasing BMI The age-adjusted prevalence among persons who are obese (25.2% for men, 33.8% for women) was approximately double that for persons who are underweight/normal weight (13.8% for men, 18.9% for women)
Among those with arthritis, the age-adjusted prevalence of AAAL also increased significantly with increasing BMI, from 34.7% for those who are underweight/normal weight to 44.8% for those who are obese.
Reported by
YJ Cheng, MD, PhD, JM Hootman, PhD, LB Murphy, PhD, GA Langmaid, CG Helmick, MD, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
Editorial Note
Approximately one in five (49.9 million) adults in the United States reported doctor-diagnosed arthritis during 2007--2009, and 21.1 million adults reported AAAL. The prevalence of arthritis and AAAL is particularly high among persons who are obese. With the aging population and continued high prevalence of obesity (3) in the United States, the prevalence of arthritis is expected to increase significantly over the next 2 decades.
Compared with previous estimates, the number of adults with arthritis increased, but not significantly (p=0.07), from 46.4 million during 2003--2005 to 49.9 million during 2007--2009, an increase of approximately 1 million adults per year (4). During the same period, the prevalence of AAAL increased significantly (p=0.005), from 8.8% (18.9 million persons) to 9.4% (21.1 million). The data on arthritis prevalence appear consistent with a previous analysis that estimated 51.9 million adults would have arthritis by 2010 and 67 million by 2030 (1). That analysis also estimated that 19.1 million adults would have AAAL by 2010 and 25 million by 2030; however, the findings in this report indicate that 21.1 million persons already had AAAL during 2007--2009 (1).
Obesity is associated with onset of knee osteoarthritis (the most common type of arthritis), disease progression, disability, total knee joint replacement, and poor clinical outcomes after knee joint replacement, and likely has a critical role in the increasing impact of arthritis on disability, health-related quality of life, and health-care costs (5). Lifetime risk for symptomatic knee osteoarthritis alone is 60.5% among persons who are obese, double the risk for those of normal/underweight (6). Because even small amounts of weight loss (approximately 11 lbs [5 kg]) can reduce the risk for incident knee osteoarthritis among women by 50% (7) and might also reduce mortality risk in osteoarthritis patients by half (8), large-scale clinical and community efforts to prevent and treat obesity as recommended by the National Institutes of Health¶ might reduce the obesity-related burden and impact of arthritis in the population.
The findings in this report are subject to at least four limitations. First, doctor-diagnosed arthritis was self-reported and not confirmed by a health-care professional; however, self-reports are sufficiently sensitive for public health surveillance (9). Second, osteoarthritis, rheumatoid arthritis, gout, lupus, and fibromyalgia have different etiologies and risk factors; however, the public health recommendations for these different types of arthritis are the same (e.g., weight loss and increased physical activity), regardless of differences in etiology or medical management. Third, because NHIS is a cross-sectional survey, a cause-effect relationship between risk factors (e.g., obesity) and arthritis and AAAL could not be determined; certain risk factors, such as obesity, could develop after onset of arthritis. However, prospective studies consistently have identified excess body weight as a risk factor for incident arthritis, particularly lower extremity osteoarthritis (5,7). Finally, because all NHIS information is self-reported, underreporting of weight and overreporting of leisure-time physical activity might have occurred because of social desirability bias.
Both clinical treatment guidelines (10) and public health recommendations for osteoarthritis** call for proven community-based intervention strategies (e.g., self-management education, increased physical activity, and weight management) to reduce pain and improve physical function and health-related quality-of-life for persons with osteoarthritis. Health-care providers and public health organizations should work together to increase the availability of these interventions for persons with all types of arthritis.
References
Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum 2006;54:226--9.
Anandacoomarasamy A, Caterson I, Sambrook P, Fransen M, March L. The impact of obesity on the musculoskeletal system. Int J Obes 2008;32:211--22.
Murphy L, Schwartz TA, Helmick CG, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum 2008;59:1207--13.
Felson DT, Zhang Y. An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis Rheum 1998;41:1343--55.
Shea MK, Houston DK, Nicklas BJ, et al. The effect of randomization to weight loss on total mortality in older overweight and obese adults: the ADAPT Study. J Gerontol A Biol Sci Med Sci 2010;65:519--25.
Sacks JJ, Harrold LR, Helmick CG, Gurwitz JH, Emani S, Yood RA. Validation of a surveillance case definition for arthritis. J Rheumatol 2005;32:340--7.
Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis. Part III: changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010;18:476--99.
* BMI = weight (kg) / height (m2). Categorized as follows: underweight/normal weight (<25.0), overweight (25.0 to <30.0), obese (≥30.0), obese class I (30.0 to <35.0), obese class II (35.0 to <40.0), obese class III (≥40.0).
† Determined from responses to six questions regarding frequency and duration of participation in leisure-time activities of moderate or vigorous intensity and categorized according to the U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans. Total minutes (moderate plus 2 × vigorous) of physical activity per week were categorized as follows: meeting recommendations (≥150 min per week), insufficient activity (10--149 min), and inactive (<10 min).
Arthritis is a large and growing public health problem in the United States, resulting in costs of $128 billion annually, and continues to be the most common cause of disability.
What does this report add?
During 2007--2009, 22.2% of adults aged ≥18 years (49.9 million) had self-reported doctor-diagnosed arthritis, and 9.4% (21.1 million or 42.4% of those with arthritis) had self-reported arthritis-attributable activity limitation (AAAL). Among persons who are obese, an age-adjusted 33.8% of women and 25.2% of men reported doctor-diagnosed arthritis.
What are the implications for public health?
Arthritis and AAAL represent a major public health problem in the United States that can be addressed, at least in part, by implementing proven obesity prevention strategies and increasing availability of effective physical activity programs and self-management education courses in local communities.
TABLE. Unadjusted and age-adjusted* prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation (AAAL)† in the adult population, and prevalence of AAAL among those with doctor-diagnosed arthritis, by selected characteristics --- National Health Interview Survey, United States, 2007--2009
Characteristic
Prevalence in the adult population
Prevalence of AAAL among those with doctor-diagnosed arthritis
Doctor-diagnosed arthritis
AAAL
Unadjusted
Age adjusted
Unadjusted
Age adjusted
Unadjusted
Age adjusted
%
(95% CI§)
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
Overall
22.2¶
(21.7--22.7)
21.4
(21.1--21.8)
9.4**
(9.1--9.7)
9.1
(8.8--9.3)
42.4
(41.4--43.4)
39.1
(37.7--40.5)
Sex
Men
18.3
(17.7--18.9)
18.2
(17.7--18.7)
7.3
(6.9--7.7)
7.3
(6.9--7.6)
40.0
(38.3--41.6)
36.9
(34.7--39.2)
Women
25.9
(25.2--26.5)
24.3
(23.8--24.8)
11.4
(11.0--11.8)
10.6
(10.3--11.0)
44.0
(42.8--45.1)
40.6
(39.0--42.2)
Age group (yrs)
18--44
7.6
(7.2--8.0)
---
---
2.7
(2.4--2.9)
---
---
35.1
(32.8--37.6)
---
---
45--64
29.8
(29.0--30.5)
---
---
12.7
(12.1--13.2)
---
---
42.6
(41.1--44.1)
---
---
≥65
50.0
(48.9--51.2)
---
---
22.7
(21.8--23.6)
---
---
45.4
(43.9--46.9)
---
---
Race/Ethnicity
White, non-Hispanic
25.4
(24.8--26.0)
23.0
(22.5--23.5)
10.4
(10.0--10.8)
9.3
(9.0--9.7)
41.0
(39.8--42.1)
38.1
(36.4--39.8)
Black, non-Hispanic
20.2
(19.2--21.2)
21.7
(20.8--22.7)
9.8
(9.1--10.6)
10.6
(9.9--11.4)
48.8
(46.3--51.2)
45.5
(42.1--49.0)
Hispanic
11.9
(11.2--12.7)
16.1
(15.3--17.0)
5.6
(5.2--6.1)
8.0
(7.4--8.7)
47.2
(43.8--50.6)
41.4
(37.6--45.2)
Other, non-Hispanic
13.6
(12.5--14.9)
15.0
(13.9--16.1)
6.1
(5.3--7.0)
6.7
(5.9--7.6)
44.7
(40.2--49.2)
38.2
(32.9--43.8)
Education level
Less than high school diploma
25.5
(24.3--26.6)
21.9
(21.1--22.8)
14.0
(13.1--14.9)
12.0
(11.3--12.8)
55.0
(52.9--57.1)
52.0
(47.9--56.1)
High school diploma
25.2
(24.4--26.1)
22.9
(22.2--23.7)
10.9
(10.3--11.5)
9.8
(9.3--10.4)
43.1
(41.3--45.0)
41.3
(38.6--43.9)
At least some college
19.8
(19.2--20.3)
20.5
(19.9--21.0)
7.4
(7.0--7.7)
7.7
(7.3--8.0)
37.3
(35.9--38.6)
34.3
(32.6--36.1)
Body mass index (BMI) category††
Underweight/Normal weight
16.4
(15.8--17.1)
16.9
(16.4--17.5)
6.1
(5.7--6.5)
6.3
(5.9--6.7)
37.3
(35.4--39.2)
34.7
(32.1--37.4)
Overweight
21.4
(20.7--22.1)
19.8
(19.2--20.3)
8.2
(7.7--8.6)
7.5
(7.1--7.9)
38.3
(36.7--40.0)
35.0
(32.8--37.2)
Obese
31.1
(30.2--32.0)
29.6
(28.8--30.4)
15.1
(14.5--15.9)
14.4
(13.8--15.1)
48.7
(47.1--50.4)
44.8
(42.5--47.1)
Class I
28.3
(27.2--29.4)
26.6
(25.7--27.6)
12.6
(11.8--13.4)
11.8
(11.2--12.5)
44.5
(42.4--46.6)
41.2
(38.3--44.2)
Class II
33.7
(31.9--35.7)
32.2
(30.5--33.9)
17.4
(15.9--18.9)
16.7
(15.3--18.2)
51.6
(48.0--55.1)
46.7
(41.9--51.5)
Class III
38.5
(36.2--40.8)
38.1
(36.1--40.2)
22.2
(20.3--24.2)
22.4
(20.6--24.3)
57.6
(53.9--61.2)
52.9
(48.1--57.6)
Physical activity level§§
Meeting recommendations
17.2
(16.6--17.9)
18.7
(18.2--19.3)
4.9
(4.6--5.2)
5.3
(5.0--5.7)
28.4
(26.9--29.9)
27.3
(25.3--29.3)
Insufficient activity
23.8
(22.9--24.7)
22.9
(22.1--23.7)
9.2
(8.7--9.9)
8.9
(8.4--9.4)
38.9
(37.0--41.0)
37.2
(34.5--40.0)
Inactive
27.2
(26.4--28.1)
23.5
(22.8--24.1)
14.8
(14.2--15.5)
12.7
(12.1--13.2)
54.5
(52.9--56.1)
51.2
(48.8--53.6)
Smoking status
Current
21.8
(21.0--22.7)
23.7
(22.9--24.6)
10.7
(10.0--11.4)
11.6
(10.9--12.3)
48.9
(46.6--51.2)
47.6
(44.9--50.4)
Former
33.6
(32.6--34.6)
25.4
(24.6--26.3)
14.1
(13.4--14.8)
10.2
(9.7--10.8)
42.0
(40.5--43.6)
36.5
(33.7--39.5)
Never
18.1
(17.6--18.6)
19.0
(18.6--19.5)
7.2
(6.9--7.5)
7.7
(7.4--8.0)
39.9
(38.6--41.2)
35.0
(33.4--36.7)
* Age adjusted to the 2000 U.S. projected adult population, using three age groups: 18--44 years, 45--64 years, and ≥65 years.
† Doctor-diagnosed arthritis was defined as those answering "yes" to the question, "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?" Those who answered "yes" were asked, "Are you limited in any way in any of your usual activities because of arthritis or joint symptoms?" Persons responding "yes" to both questions were defined as having an AAAL.
§ Confidence interval.
¶ 49.9 million adults.
** 21.1 million adults.
†† BMI = weight (kg) / height (m2). Categorized as follows: underweight/normal weight (<25.0), overweight (25.0 to <30.0), obese (≥30.0), obese class I (30.0 to <35.0), obese class II (35.0 to <40.0), and obese class III (≥40.0).
§§ Determined from responses to six questions regarding frequency and duration of participation in leisure-time activities of moderate or vigorous intensity and categorized according to the U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans. Total minutes (moderate plus 2 x vigorous) of physical activity per week were categorized as follows: meeting recommendations (≥150 min per week), insufficient activity (10--149 min), and inactive (<10 min).
FIGURE. Age-adjusted* prevalence of doctor-diagnosed arthritis among adults, by sex and body mass index (BMI) category† --- National Health Interview Survey, United States, 2007--2009
* Age adjusted to the 2000 U.S. projected adult population, using three age groups: 18--44 years, 45--64 years, and ≥65 years.
† BMI = weight (kg) / height (m2). Categorized as follows: underweight/normal weight (<25.0), overweight (25.0 to <30.0), and obese (≥30.0).
Moderate drinking may have some heart-healthy benefits, but its protective effects might not stop there. A new study suggests that alcohol might diminish the intensity of rheumatoid arthritis symptoms and could lessen the risk of getting the disease.
The study, published online this week in the journal Rheumatology, examined drinking frequency in 873 white men and women with erosive, or inflammatory, RA, as well as 1,004 healthy people. In questionnaires, they were asked how many days over the last month they had had at least one alcoholic drink. They were also asked if they never drank, ever drank, or were a regular drinker.
Those with RA who had a history of most frequent drinking had less serioussymptoms than those who never drank or drank infrequently.
In X-rays, those who drank more frequently showed reduced joint damage, and blood tests revealed less inflammation compared with those who drank less frequently. There was also less swelling, joint pain and disability among the more frequent drinkers.
People who never drank were four times more likely to develop RA than those who drank alcohol on more than 10 days a month. The findings cut across gender lines.
As for why alcohol may have a positive effect on RA, its effect on immune system suppression may be a key. "There is some evidence to show that alcohol suppresses the activity of the immune system, and that this may influence the pathways by which RA develops," lead author Dr. James Maxwell, a consultant rheumatologist at the Rotherham Foundation NHS Trust in Britain, said in a news release. "Once someone has developed RA, it's possible that the anti-inflammatory and analgesic effects of alcohol may play a role in reducing the severity of symptoms."
