November 2008 Issue

Healthy Living Through the Holidays
By Rita E. Carey, MS, RD, CDE
Today’s Dietitian
Vol. 10 No. 11 P. 40

Because it’s so easy to overeat during the holidays and derail health and fitness goals, RDs should arm their patients (especially those with diabetes) with tips for resisting the season’s temptations.

The holiday season poses some common challenges to Americans’ health and wellness. This time of year, people struggle with weight gain, and people with diabetes will likely also struggle with blood sugar control. Dietitians and diabetes educators can help patients recognize the challenges inherent in the holiday season and assist with developing plans to deal with them.

Holiday Weight Gain: The “Gift” That Keeps on Giving
Research suggests that on average, individuals gain less than 1 pound over the six-week period from mid-November to early January.1 Although this amount of weight gain may seem trivial in the short run, its long-term impact on health may be substantial.
The problem with holiday weight gain seems to be related to our inability to lose the pounds we have added over the course of a year; thus, we accumulate more of them as the years roll by. One of the first studies examining holiday weight gain found that in a study group of approximately 160 people, most gained an average of 1.4 pounds over the course of a year.1 About one half of the weight gain was observed over the six-week holiday period, and participants did not lose that weight but added more in subsequent months. Researchers concluded that adult weight gain occurs slowly, mostly during the fall and winter months, but adds up over the years.

Research also suggests that body composition changes may occur among some populations during the holidays, adding to the risk of future weight gain. A small study published in Nutrition & Metabolism in 2006 that examined college-aged students’ holiday weight gain concurrently measured changes in body composition. This study documented an insignificant overall weight gain during six weeks (pre-Thanksgiving to post-New Year’s) in this population but found a significant increase in body fat and concomitant decrease in fat-free mass. Participants demonstrated weight gain over Thanksgiving (the obese/overweight group gained an average of 1 kilogram of body weight, while the normal body mass index [BMI] group gained an average of 0.2 kilograms), but most had returned to their preholiday weight when they returned for a follow-up after New Year’s. (The authors noted that participants knew the focus of the study was holiday weight gain, which may have influenced outcomes.)

However, although body weight did not increase overall, the percentage of body fat did increase, irrespective of BMI. Over the short holiday period, researchers measured a significant increase in trunk fat mass in all groups and a significant decrease in leg and arm muscle mass. The authors noted that “this is particularly worrisome given that excessive accumulation of trunk fat is related to a host of comorbid conditions such as cardiovascular disease, type 2 diabetes, and early mortality” and “as most individuals judge overall health based on their body weight, these subjects would not consider themselves at higher risk of developing future disease.” This study also suggests that those at highest risk for seasonal weight gain are those who are already obese.

Environmental Contributions to Weight Gain
How do the holidays increase people’s risk for adding on pounds? In a 2004 Annual Review of Nutrition article, Brian Wansink, PhD, author of Mindless Eating: Why We Eat More Than We Think, identified a number of environmental factors that can lead to overconsumption during social gatherings and celebrations. Long eating duration (as is typical at parties and other social gatherings), easy access to foods (leftovers from holiday meals, visible snacks and treats laid out at home and at work), multiple distractions while eating, the availability of large stockpiles of foods, an increased variety of foods, large portions, and the social norms that condone overeating all likely contribute to holiday weight gain.

The relatively easy access to a large variety of foods during the holidays may be one of the biggest contributing factors; according to Wansink, the level of effort needed to access and consume food is one of the strongest influences on consumption. The distractions inherent in holiday socializing (conversations, media, and events) also encourage increased consumption, likely by making it more difficult to notice satiety signals. Interestingly, studies indicate that meals eaten with one or more other people may increase the quantity of foods people eat by 33% to 96%.2,3 Apparently, holidays present a number of environmental conditions that can cause us to eat more than we need or intend.

The Role of Exercise
People generally exercise less often during cold-weather months, and this seasonal variation in exercise frequency may also contribute to both holiday and annual weight gain. Expending fewer calories while taking more in over the holidays will undoubtedly lead to weight gain during this relatively short period of time. In addition, some evidence indicates that seasonal exercise fluctuations may contribute to long-term weight gain in a less obvious manner.

A very large study published recently in Medicine & Science in Sports & Exercise assessed whether the weight people accumulated during periods of diminished activity could be equally lost after they resumed usual activity levels. Researchers collected data from a population of runners (n = 54,956) who participated in the National Runner’s Health Study between 1991 and 1993, with follow-up data collected in 2000. They found that runners who regularly ran less than 32 kilometers per week (men) or 16 kilometers per week (women) who reduced or stopped running for a period of time could not lose the amount of weight they gained during inactivity if they resumed exercise at their normal rate. The study authors also mentioned that reduced abilities to lose weight after inactivity may be related to the loss of fat-free mass. 

Blood Glucose Control
Impaired glycemic control among people with diabetes during the holidays may mirror both holiday and annual weight gain patterns in the general population. Evidence suggests that like body weight, hemoglobin A1C levels rise during the holiday season and, similarly, are unlikely to return to preholiday levels later in the year. Thus, as weight slowly increases from year to year among the general population, A1C levels may also slowly rise over time and seem to rise more significantly during the holidays in individuals with diabetes.

A study conducted in China and published in 2004 in Diabetes Care found that subjects’ A1C levels increased 0.198% during the holidays (December 20 to January 20 and January 28 to February 28) but decreased only 0.009% over the course of the subsequent year. Although China  has a different holiday season from the United States, the holidays considered here cover approximately the same amount of time and occur during the winter months, as they do in the United States.  

What to Do?
Weight gain, elevated blood glucose levels, and increased A1C levels are inherently interrelated. Monitoring for gradual weight gain via frequent weighing during the holidays may be a good first line of defense against rising A1C levels. Carefully tracking intakes and postprandial blood sugars is also helpful for preventing both weight gain and hyperglycemia. A small study published in 1998 in Health Psychology found that participants who recorded meal and snack intakes most consistently over a 10-week period actually lost weight while those who were less consistent gained weight.

Making changes in the home, work, and eating environments will reduce the number of opportunities individuals have to overconsume. Wansink offers several ideas to change a person’s environment to eat less. (See sidebar for some ideas summarized in Mindless Eating.)

Maintaining a regular exercise program is also important. Considering the research on runners, educators should let patients know that reduced activity during the holidays (secondary to inclement weather, busy schedules, or other distractions) may make any weight gained during this period increasingly difficult to lose. Maintaining a consistent exercise program year-round appears key to long-term weight maintenance. Individuals should also know that the amount of exercise required to maintain weight loss over a period of years is likely larger than is generally recommended. After studying 24-month weight loss maintenance in 201 overweight women, Jakicic et al concluded in a 2008 Archives of Internal Medicine study that 275 minutes per week of regular physical activity was necessary to maintain a 10% loss of body weight. This amount of exercise translates to about one hour of activity five days per week uninterrupted for two years. The study suggests that the amount of activity needed to sustain substantial weight loss is about twice the current public health recommendations (30 minutes of activity five days per week).

Some Observations From Real Life
Many people manage to make it through the holidays with stable weight and blood glucose levels. Some people who attend our local, monthly diabetes support group offer the following words of wisdom to those seeking to stay in good control:

• Don’t go to a dinner or a party hungry, especially if there is a buffet.

• Remind yourself how you would like to feel at the end of the night. Do you want to feel light and energetic or full and sluggish?

• Allow yourself to drink alcoholic beverages twice per week, but don’t drink more than two.

• Work sweets into your daily carbohydrate plan. You may want to subtract a few grams from your plan during the holidays because sweets generally spike blood sugar levels more than other carbohydrates.

• Pay attention. Keep track of how many times you start to eat something because you see it, not because you are hungry. If you find you are often eating when you are not hungry, you will likely gain weight.

More Vegetables and Less Fat
Barbara J. Rolls, PhD, has done some of the most intriguing research on Americans’ eating habits in recent years. In her book Volumetrics: Feel Full on Fewer Calories, Rolls wrote that it is the volume of our meals, not the calories or macronutrient composition, that most significantly impacts satiety. She explained that by increasing the volume of food at meals and snacks (usually by adding vegetables and other foods with considerable water content) and decreasing the calorie density (eg, by reducing fat), individuals can feel sated with meals containing fewer calories.
 
One may apply a similar strategy to preparing meals and snacks during the holidays. A holiday meal that includes a large variety of vegetable dishes and a small number of meat and starch-based dishes will likely help guests choose more of the higher volume, lower calorie dishes.

Need a tasty holiday spread for bread or a dip for crackers or vegetables? Try Chef Molly Beverly’s Red Pepper Spread (below), which has significantly fewer calories and less fat than butter and most sour cream- or mayonnaise-based dips.

Staying healthy through the holidays need not be a Sisyphean task. Taking the time to work with clients on strategies to get them around their biggest challenges, teaching them how to change their environment and habits, and encouraging regular exercise can help them prevent weight gain and hyperglycemia. Preventing seasonal weight gain and hyperglycemia has long-term benefits, and patients should be made aware of this as well. 

— Rita E. Carey, MS, RD, CDE, is a clinical dietitian and diabetes educator at Yavapai Regional Medical Center and the Pendleton Wellness Center in Prescott, Ariz.

• Do not leave serving bowls and platters on the table. Keep second servings a safe distance away.

• Decide how much to eat prior to the meal or event.

• Model the behavior of the person in the room or at the table who seems to be eating the least or most slowly.

• At buffets and receptions, avoid having more than two different foods on the plate at the same time.

• Wrap tempting foods in foil or in nontransparent containers.

• Place lower calorie, nutrient-dense foods toward the front of the refrigerator and cupboards. Make higher calorie, easy-to-eat snack foods and entrées more difficult to reach.

• Use smaller plates and bowls. Use smaller serving utensils.

• Stockpile healthier foods instead of high-calorie foods.

• Reduce the visibility of foods that are easy to eat.

— Source: Wansink B. Mindless Eating: Why We Eat More Than We Think. Bantam Books; 2006.

Chef Molly Beverly’s Red Pepper Spread
Molly Beverly is the chef at the Prescott College Crossroads Café in Prescott, Ariz. Her red pepper paste, served with whole grain bread, crackers, or vegetables, has been a hit for many years in diabetes classes and served year-round at home. Depending on the type used, the hot chili can make the spread mild or very hot. Use this spread as a substitute for butter on bread, as a dip for vegetables, or as a topping for potatoes. The red color of the bell peppers is perfect for the holidays.

Ingredients:
11/4 lbs fleshy red bell peppers, cored and coarsely chopped
1 small hot chili (jalapeño, Serrano, or other), seeds removed
Pinch of sugar
1/4 tsp salt
2 tsp extra-virgin olive oil

Directions:
Purée the bell peppers and chili with 2 tablespoons of water, the pinch of sugar, and the salt in a food processor or blender until smooth. Transfer to a saucepan and cook over medium heat, stirring often, until purée is reduced to a jamlike consistency (ie, let it get pretty thick). Blend in the olive oil. Chill before serving.

Makes about 2/3 cup

Nutrient Analysis for 2 tablespoons:
Calories: 47
Protein: 1 g
Carbohydrate: 7 g
Fat: 2 g
Fiber: 2 g
Sodium: 115 mg
 
Recipe reprinted with permission of Chef Molly Beverly

References
1. Yanovski JA, Yanovski SZ, Sovik KN, et al. A prospective study of holiday weight gain. N Engl J Med. 2000;342(12):861-867.

2. de Castro JM. Eating behavior: Lessons from the real world of humans. Nutrition. 2000;16(10):800-813.

3. de Castro JM, Brewer EM. The amount eaten in meals by humans is a power function of the number of people present. Physiol Behav. 1992;51(1):121-125.