Expert Conversations: Counseling Patients About Nutrition Around the Holidays

In this video, Andrew Freeman, MD, leads a panel discussion around nutritional counseling in the cardiology clinic. Panelists include Emilio Ros, MD, PhD; Monica Aggarwal, MD; Robert Ostfeld, MD, MSc; James O'Keefe, MD; and Penny Kris-Etherton, PhD, RD. 

Andrew Freeman, MD, is a cardiologist at National Jewish Health in Denver, Colorado.

Emilio Ros, MD, PhD, is the director of the Lipid Clinic and senior consultant of the Endocrinology and Nutrition Service at Hospital Clínic in Barcelona, Spain. 

Monica Aggarwal, MD, is an associate professor of medicine in the Division of Cardiovascular Medicine at the University of Florida in Gainesville, Florida.

Robert J. Ostfeld, MD, MSc, is the director of Preventive Cardiology at Montefiore Health System and a professor of medicine at the Albert Einstein College of Medicine in the Bronx, New York.

James H. O'Keefe, MD, is a cardiologist and medical director of the Charles and Barbara Duboc Cardio Health & Wellness Center at Saint Luke’s Mid America Heart Institute, and a professor of medicine at the University of Missouri-Kansas City.

Penny Kris-Etherton, PhD, RD, is distinguished professor of nutrition at Penn State College of Health and Human Development. She is also the chair of the AHA Council on Lifestyle and Cardiometabolic Health and Past Chair of the AHA Nutrition Committee.

TRANSCRIPT:

Andrew Freeman: Hi, everyone. My name is Andrew Freeman. I’m a cardiologist at National Jewish Health in Denver, Colorado. I'm joined today by my esteemed colleagues with an important topic, which is discussing how to eat well over the holiday season.

As you may know, for those of you in clinical practice, you're probably asked this question multiple times a day particularly this time of year. So, our hope is to add a little clarity for you in your day-to-day practice.

I'm joined by Dr Robert Ostfeld, Dr Penny Kris-Etherton, Dr Emilio Ros, Dr Monica Aggarwal, and we are very excited to talk about this. I'm going to open up the floor and ask folks today a little bit about what they recommend.

So, when a patient comes in and says, “Doc, what can I eat over the holidays that is healthy?” What do you say? Why don't we start with Monica? Monica, what do you tell people?

Monica Aggarwal: I always tell people that it's nice to have treats once in a while, so not to sort of feel bad about the holiday eating. It should be about eating healthy most of the time, and if you have a treat once in a while, not to fret about it and always enjoy the moment.

But I do tell people that the goal is not to eat desserts all day, and then say, “Oh, well, one more treat won't hurt.” Usually, I tell people that if you try to just work really hard all day, and then maybe at night you have a little extra you have a little extra dessert around the holidays, that's okay.

The other thing I often tell people, like when you get invited to holiday parties—albeit maybe not this year because of COVID-19—always bring the healthy option so you have something that you can eat when you're at a holiday party. There's not that stress of, “Oh gosh, what am I going to eat? There was nothing for me.”

Andrew Freeman: Great. How about you, Rob? What do you tell people in New York when they're going to these decadent holiday parties? What should they do?

Robert Ostfeld: Well, I'm on the same page as Dr Aggarwal. I will say that we don't want perfection to be the enemy of good. So, I certainly encourage patients to—even during the holidays—ideally, I'll go 333. Three servings of green leafy vegetables a day, 3 servings of other vegetables, and 3 servings of fruit a day.

But we don't want perfection to be the enemy of good, and having a treat from time to time is certainly a great idea. A particular treat that I like to steer patients toward is dark chocolate, which can be quite helpful. It has a lot of cacao in it. Particularly, from my perspective, it’s one with less dairy in it, but that can be a really nice treat for people to have.

There's certainly an abundance of data that shows that every little bit, every step we take to eating a more helpful dietary pattern is indeed helpful for us. So, I'm with the “don't let perfection be the enemy of good” school of thought here.

Andrew Freeman: Okay and, Penny, what do you tell people? You're in in the heart of Pennsylvania, where people may not want to eat the healthiest stuff.

Penny Margaret Kris-Etherton: Absolutely. Well, the holidays are a real special time and a happy time for people. I think to make them even more special, I tell them always think about health. Think about fruits and vegetables, and the really neat, exciting things you can do with them.

There are a lot of really special ways to prepare fruits and vegetables that you don't normally do when you're cooking. So, for example, people can do interesting things with dates and with pomegranates and with figs and just spice them up. Use some nut butters with them, and even roll them in nuts to make them special.

With pomegranates, they could use them to season a lot of different vegetables, in particular sweet potatoes or squash. If they just think about making the foods that they normally eat, like plain old green beans, more special, it's a great time to celebrate the holidays in that way.

Andrew Freeman: That's a great point. That sounds colorful too. Emilio, you're our token non-US person. So, here you are in Spain, where people are, in theory, eating more healthfully than other countries in the world. So, the holidays come. What do you recommend for people there?

Emilio Ros: Presumably, they eat healthier throughout the year, but sometimes it’s not so. The worst problem with Christmas, with the holiday season here—here in Spain it’s Christmas, because we don't celebrate Thanksgiving—is overeating and then gaining weight.

This is really a problem, which is common also in the United States. I remember there being a landmark paper 20 years ago in the New England Journal of Medicine, where some NIH investigators asked candidate NIH personnel what they ate before, during, and after the holidays. They gained just a pound or less on average.

The problem is that they didn't lose this pound after. So, this was accumulated with the pound from the year before or the pound that will accumulate next year. That probably contributes to the epidemic of obesity, because during this time you overeat and then “boom.”

In Spain, we don't have so much this problem of obesity. I do like Penny with my patients. I tell them about the healthy foods, lots of vegetables, ways to cook them. Olive oil helps to eat lots of vegetables.

But obviously for the real holidays, which is Christmas Eve, Christmas day, New Year's Eve, New Year's Day, and then the King’s Day—also in Spain, we have January 6 as a big festivity; that's when the kings from the East used to bring gifts to children and now it's Papa Noel (Santa Claus).

But anyway, these days there’s nothing you can do. I mean, you tell them to eat traditionally, that means beef stew, lots of meat, and processed meat inside. That goes with lots of vegetables also. A big stew, which is traditional Christmas stew, and you say that's once a year. No problem.

But then there is the nougat, turron in Spanish. This is also the traditional dessert at Christmas. It's made with almonds, but also with egg and sugar and pinions. It’s really a caloric bomb, but it's not so bad because it has lots of nuts and it’s only eaten for Christmas.

Obviously, you're probably in your right mind to prohibit eating that to people with obesity or diabetes, and so we advise some control. These days, that’s obliged almost. What we emphasize is that the rest of the year you eat vegetables, you don't eat the sweets, etc. But for these particular days, we allow it. I mean, it’s tradition also.

Andrew Freeman: So, you give them a pass, even though some of their traditions may hurt them?

Emilio Ros: Only if they are diabetic or obese, be aware of nougat, beware of champagne. Otherwise, for the common people, these days they can treat themselves.

Andrew Freeman: Fair enough.

Emilio Ros: It’s very difficult to do otherwise.

Andrew Freeman: And then we're also joined by Dr James O'Keefe, who is with us. In the middle of America where he practices, I can only imagine what he faces for the holidays. What do you tell your patients?

I'll just tell the audience that my favorite thing you've ever taught me, James, is about garbage carbs. The term you called “carbage,” which I use all the time. So, tell us a little bit about what you recommend in that vein, and so forth.

James O'Keefe: Well, as usual, when it comes to practical dietary advice, I really lean on my wife, Joan, who's a dietitian. Very practical, smart tips on diet, and she has for years told people around the time of the holidays that you want to focus on good things first.

So, when people show up—as she says, “start circling around, looking for food”—you have trays of nuts and vegetables cut up with humus to dip or maybe peel-and-eat shrimp with some cocktail sauce, guacamole with vegetables. These are foods that are delicious that will fill people up so that when the rest the meal comes up, you eat some fiber and protein, they're less hungry.

She also mentions that, instead of just drinking alcohol all the time, maybe put out lots of sparkling water, not artificially sweetened or sweetened carbonated beverages, but sparkling water that has all these great flavors. A lot of people are addicted to that. It's a super healthy treat. So, you could maybe substitute some of that for the alcohol.

And then for dessert, she says—I mean, I normally don't eat dessert—but when you choose a dessert, find something that has some redeeming values, like pumpkin pie with some antioxidants in it, or peach cobbler, apple pie, things like that, berries with some whipped cream.

Yeah, if there's a will, there's a way. If you sabotage people when they're hungry and put out all those healthy snacks, it does subconsciously force them to eat healthier and choose healthier foods.

Andrew Freeman: Well, you bring up some really good points. First, a lot of people actually drink a lot of their calories on the holidays, right? In addition to alcohol, there's eggnog and punches and sodas and all kinds of stuff. So, I think that's a really important point.

And the other thing that you bring up, I think is probably critical, is load up on the veggies first. I usually tell people, especially those that are trying to be healthy or they have a crazy cardiologist like me, I tell them to bring the veggie tray.

I tell them to throw out the ranch and put hummus in instead and see if that will do the trick. A lot of times that's actually been the winner. I would also tell you that one of the things we run into all the time, and I'd be curious to hear what everyone has to say, about what the main course around a lot of the holidays is, which is ham.

And as we all know, ham is loaded with salt and depending on how its processed, in most cases it's considered to be carcinogenic. Yet, we eat it in large, large quantities. So, I'm curious what you all say when people say, “Well, can’t I have a piece of ham?” What do you guys say?

James O'Keefe: I often say a little bit of red meat won't kill you. But that being said, ham is processed meat and so that's particularly bad. I encourage people to try to choose turkey around the time of the holidays.

Andrew Freeman: Yeah, I'm with you. When I hear, “Can I have a little bit of ham?” I'm like, “Well, can you smoke a cigarette here or there?” And they are like, “Well, no.” And I'm like, “Well, I want you to consider that It's not good for you in that way.”

Of course, I'm sure you have the same thing where you have the epidemic, not just the surge of COVID-19 after the holidays, but the surge of heart failure after the holidays.

Just a few bites of ham, I think, has as much sodium as you might need for a couple of days or even a week, depending on how much you eat. I get that question quite a lot, especially here in Colorado, where a lot of people are raising animals.

Well, let's move on to a few other topics. One of the things that was brought up was about nuts. Now it's an interesting tradition in a lot of cultures, not only in the United States but overseas.

Nuts are very tasty. They're very rich and quite delicious, but you'll find that virtually everything is rolled in nuts or nuts added or nut butter added. It sure makes something relatively boring fantastic. I don't know if you've had a peanut-encrusted grape, but what a great idea! Who came up with that?

At the same point, it's easy to probably exceed them. So, I'm curious what you all recommend regarding nuts.

Penny Margaret Kris-Etherton: Well, one thing I think is good is to get people to eat whole nuts that they crack themselves, rather than take a whole handful of salted or sugared nuts and toss them down. They're sitting there, cracking nuts and then visiting with people. It's a way of slowing down eating and controlling calories.

Andrew Freeman: That's a great point. I think the worst thing ever invented was shelled pistachio nuts. Those are easy to go through for sure.

Emilio Ros: That’s a very good snack, because they have a high energy density. So, then you eat less of another food. There is lots of evidence that nuts don’t fatten. You don’t gain weight by eating nuts, in spite of the high density. Then you compensate by eating less and usually eat less unhealthy foods. So, nuts are really excellent.

Andrew Freeman: Rob, what do you think about nuts?

Robert Ostfeld: Well, I'm pro nuts. I eat them myself, and I share everybody’s thoughts here. If you start off eating a handful of nuts, particularly raw, because they can be really salted and have all kinds of stuff put on them.

I encourage people to have raw nuts. It can start to fill you up and give you less space and less appetite for more of the junkier stuff that you would have later. In terms of the nut butters, I think they're great. They’re easy to have a lot of.

Sometimes a nut butter can just be ground up peanuts or almonds, or whatever. It also can be ground up peanuts, almonds, and tons of sugars, and all kinds of other additives. So, I always encourage my patients to get the one that's just the ground up and not the one with like 7 other ingredients.

Andrew Freeman: Yeah, that's a great point. I actually never really discovered peanut butter. I always thought it came in that jar with a brand on it. There's a whole bunch of them growing up when I was a kid. And then you go to the local grocery store now, and you literally grind it up right there. The only ingredient is peanuts or almonds. I had no idea how good peanut butter can be so that's an interesting one.

Robert Ostfeld: It's great to grind it, but I'm sure where you are all throughout the country, they sell individual jars of just the ground nut not with all that other added stuff.

Andrew Freeman: Yeah, there's a lot of added sugars and actually a lot of added oils in some of them as well, which is certainly interesting.

James O'Keefe: Emilio will tell you, in Spain and the Mediterranean countries that they use a lot of delicious extra virgin olive oil on their vegetables to get people to eat more of them. I often will tell my patients that the healthiest foods you can eat—things like nuts and vegetables and fish—you will eat more of if you can put a little salt on them, too.

Those natural foods that aren't processed are virtually sodium free. I tell people to eat those healthy foods like nuts and fish and vegetables steamed vegetables and then add olive oil and salt to taste. I find that that will encourage eating healthy foods, too.

Andrew Freeman: Well, you must be reading my mind. That's a natural segue into oils and additives. Where I trained in Philadelphia, which had a lot of the Southern influence, it's interesting in the southern United States, for those of you not familiar, it's called the “stroke belt,” because there's an enormous amount of cardiovascular disease in that area.

Interestingly, or conversely, it's actually their diets are very, very rich in super foods—kales and collard greens and mustard greens and all these things that most of us probably don't eat very often. However, they're highly adulterated. I always tell people that if you were to take the piece of paper that I'm writing on and add oil and ham hocks and all these other things, all of a sudden it becomes the most delicious decadent thing. They do the same thing with root vegetables.

So, I'm curious how you help people when they say, “Well, doc, how do I prepare my vegetables, my meats, my iced tea, whatever it may be, so that it doesn't hurt me in the long run?” There's an interesting moderation problem in the United States where people have trouble moderating their oils and their sugars and spices and all that. So, I'm curious what you all do. And so maybe, Monica, we’ll start with you.

Monica Aggarwal: Sure. I am in the heart of the South, and I've been told many times, “Doc, you're from the North, right?” And so, yes, I am from the north, but we do see a lot of people who drink sweet teas and, just like you say, eat these overcooked vegetables that are immersed in heavy oil and a lot of pork fat and ham hocks, that kind of stuff.

One of the things I often tell patients that I think is important is that what you're doing isn't working. That's why you're in my clinic. We have high blood pressure; we have high cholesterol. What we need to do is find a way that you can eat the foods you like but in a healthier way. And so, people will say, “Well, this is what I'm used to eating,” but if you explain to them, “Well, that isn't working. Why don't we try another way? Instead of eating pork, try eating fish.” Just like what was discussed before.

In terms of vegetables, I often will ask patients to eat those dark greens, which often they do love—shard and collard greens—and then just try to do either steam them. I also recommend using collards as a wrap. So, we'll do a lot of beans in a collared wrap and make a little burrito out of it. Sometimes people just have to think out of the box.

If they really want to use oils, I will recommend that they lightly sauté in oils. If they are more attentive to the food in a really sitting on top of it, you really don't need that much oil. Then adding in a lot of spices will add in a lot of flavor to those without adding all that additional oil. So those are the things I tell them to do with vegetables.

People are amenable and open to trying if you give them options and recipes. We've been really successful with that here in Florida.

Andrew Freeman: James and Emilio, I'm sure you know that olive oil is tasty. It makes vegetables tastier, for sure. How do you prevent people from overindulging? Because you can take a plate of green beans that might have a few hundred calories and then cover it in olive oil, and then it becomes many hundreds of calories. How do you tell people to not overdo it?

Emilio Ros: Well, we tell people to overdo it, precisely! If you recall the PREDIMED study, we gave participants in the olive oil arm 1 liter of olive oil per week, so they could really power all of their salads and their greens and fry with it.

They consumed, on average, 4 tablespoons of olive oil per day. And after at least 5 years, that’s how long the study lasted, they didn't even gain half a pound. It’s like with nuts. Olive oil doesn't fatten. It allows you to eat many more greens. In Spain, we don’t limit olive oil, just the contrary.

Andrew Freeman: Right, so I guess in the United States, one of the things that I've seen many a year—and I grew up on the East Coast, so your meal wasn't complete unless you had 3 different meats and every vegetable was doused in oil. So, you ended up with a plate that was probably 8000 calories or more. And then the next day, you’d pay for it. I think Spain might be unique.

James, of course I know that you eat quite well, but I don't know about all your patients. So, how do you help them maintain their isocaloric calorie count, if you will, so they don't overdo it and gain weight?

James O'Keefe: Yeah, calorie counting doesn't work, of course. And so, what you have to rely on, and I try to tell my patients … As Emilio was saying, you rely on eating satiating foods. So, when you eat nuts, and you put olive oil on your vegetables, and you eat legumes and a modest amount of healthy protein like fish or skinless poultry, nonfat dairy, I think that people are naturally filled up more.

But it's hard in this modern world where everything is engineered to taste so great, and it's inexpensive. It's everywhere. And you get addicted to it, but I think eating a lot of fiber, adding the healthy fats, modest amounts of protein. What's really important is trying to, as almost as much as possible, eliminate refined carbohydrates. That's so key to get no sugar, no white flour. I mean really try to minimize those.

Emilio would say you can't do say “no white flour.” I'm a little bit of maybe sourdough bread in moderation. But for the most part, most Americans eat way too much refined carbohydrates. That just gets your insulin levels high, insulin resistance, and leptin resistance. And then it's impossible.

Andrew Freeman: So, you might say no stuffing then?

James O'Keefe: Yeah, I'll probably skip the stuffing.

Andrew Freeman: Yeah, and I think the thing that I actually tell my patients, especially if they don't want to eat more a plant-based or healthful meal, is to take cues and stop when they're full. We all have those uncles who like to unbutton their pants, or whatever it may be, and go for another round at the table. If you're unbuttoning your pants, you’re full.

How about Penny or Rob? What advice do you give?

Penny Margaret Kris-Etherton: In terms of getting people to eat vegetables, I tell them to roast vegetables and get an oil sprayer. So, you could put olive oil in a really neat vegetable sprayer, and it's great to put on a cookie sheet. You could put broccoli, cauliflower, I use it for kale all the time. Last night we had brussels sprouts.

And you put them all on this cookie sheet and then you just spray a little bit of olive oil on it and then you season them up with all these different herbs and spices. Stick them in the oven and then roast them and they're so delicious and filling, too. Very satisfying without a lot of calories.

Andrew Freeman: That's a really smart thing, and I would encourage our listeners to consider also an air fryer, which is a really great way to either with no oil or limited oil if you're trying to count calories or reduce calories, produce surprisingly good results. Rob, what do you think?

Robert Ostfeld: I work here in the Bronx, New York City, and unfortunately obesity is extremely common. And sometimes I'll hear about patients eating vegetables that will be cooked within an inch of their life. So, I’ve been encouraging patients to steam them, to sauté them in vegetable broth, and then adding spice or mustard or hot sauce afterward for flavor.

In large part, because I'm trying to bring down the caloric density of what they're eating, I’ll encourage them—just like everyone else is saying—to fill up on those kinds of vegetables. They’re high in fiber, space occupying, so that you would have less desire hopefully to eat the junkier food down the line.

So, I think small amounts of oil can be very helpful. If you want a sauté pan with that, that's great. But I do encourage patients to limit that. I know obesity is incredibly common, but it is really common here in the Bronx.

Andrew Freeman: Great point. And then in our last few minutes, let's talk a little bit about time-limited or intermittent fasting. I want to point out that it's an interesting phenomenon that most Americans participate in, particularly on the holidays.

A lot of people will have their only meal of the day at 3:00 at Thanksgiving or Christmas dinner, whatever it may be. So, I always ask people, “How did that work out for you?” and they're like “Well, I took a walk with my kids in the morning. I played a little football. And then we had our meal. And we were done by 5:00.” So, they really limited their calories to about 2 hours in a day.

So, I'm curious if folks have comments about how that's worked with their patients. And then do you use it as a jumping off point to start the new year in a healthier eating mindset?

James O'Keefe: I'm a huge fan of intermittent fasting, time-restricted eating is a good way to do it. Some people call that the Warrior Diet; you eat one meal a day. I don't think that's necessary.

Some people still manage to stay obese or overweight when they eat once a day, because they just completely overindulge. Then they spike their triglycerides and their sugar. But I think it is a good idea to narrow the window of time during which you're consuming calories. Particularly people love to skip breakfast instead of their evening meal.

But if you don't skip a meal at least try to eat earlier in the afternoon or evening. Then don't eat anything after that, because those calories that you consume in the evening raise your insulin levels. When you're not moving around to burn the calories, they go right inside your abdomen and cause truncal obesity. So yeah, I think it's a good idea to narrow that window of time to some degree.

Andrew Freeman: And does anyone else make recommendations like that?

Monica Aggarwal: Yeah, I tell patients often to do similar to what James is saying about not eating in the evening. So, eating a nice healthy breakfast, maybe a snack, and a nourishing lunch that's maybe at 2:00 or 3:00, and then you're done for the day. I find that that has been the most effective way for me to get people to eat maybe some of the foods that they want over the holidays, but then they can still stay trim.

Even for patients who are not during the holidays, it's been the most effective way for me to get people to lose weight. Now I know the studies show that intermittent fasting in terms of weight loss is really not that much different than any other way to restrict calories. But I think, in general, if we just focus on not necessarily focusing on the name or the title, but just not eating in the evening.

So, if you stop eating after your midday meal at 3:00 or 4:00, and then not eating again, most of the patients tell me that their clarity is better; they find that they trim down so quickly; they're more energized in the evening and they're not falling asleep after that evening big meal, where they unbuckle their pants and fall asleep at the at the table or on the couch right after. So that's been really effective.

Andrew Freeman: I think it's a good point. James, you know a little bit more about this. When the body creates ketones from not eating all the time that there's some benefit to that. I'm wondering if you could share that with folks?

James O'Keefe: When you stop eating for about 12 and especially 18 hours a day, you've burned through your glycogen stores, and you start tapping into fat stores—typically intraabdominal fat stores—from the fatty acids and then make them into ketones.

We used to think that ketones were a super fuel, and they are to some degree, but it turns out that maybe the most important thing is that there's epigenetic changes that happen when you fast for a period of time, even 12 or 24 hours, that turns on a whole cadre of genes that can reduce inflammation and improve longevity.

I'm not sure that it's all about ketones, but it reminds me of an old Mediterranean proverb that says, “Eat breakfast like a king, lunch like a shopkeeper, and dinner like a pauper.” So, frontload your calories and stop eating earlier in the afternoon or evening.

Andrew Freeman: To me, the results have been interesting with my patients who have had resistance to weight loss. I have them up their exercise, eat more fiber so that they stay full—so more plant-based—and then restrict their eating between, say, 11:00 and 5:00, so 6 hours in a day. For a lot of folks, that's been the magic recipe for weight loss that they were never able to achieve. Again, everyone's mileage will vary, but I think that's an important point.

I usually use the holidays as an example when they say, “Well, I only eat one meal.” I’m like, “Great. That's how I want you to do it. Not one meal but restricted eating.” I will tell you that most people probably the equivalent of 2 meals during that timeframe.

It’s restricted over a period of time and see how it works. I think the data is rapidly emerging in that fasting is probably more physiologic than we probably thought. Interesting. Rob, what do you think?

Robert Ostfeld: Well, to be honest, here in the Bronx, when I mention eating much more of a plant-forward diet, I’ll often get looked at like I'm from Mars. When you start bringing up fasting on top of that, it’s really sometimes a bridge too far. So, it's not something that I've really incorporated much into my practice.

I focus more on helping them along the lines of what everyone has said here, consuming more minimally processed plant-based foods. We've certainly had plenty of patients lose weight and improve that way. I do think that the intermittent fasting has a lot of promise, and it's a wonderful thing to pursue, but it's really not something that I've woven into my practice here.

Andrew Freeman: I would agree with that. I think when you ask people to go plant-based or plant-forward or plant-like or whatever words you want to use, I usually don't hit them with intermittent fasting in the same visit, because you're right, they will never come back.

So, I usually wait until they say, “Doc, I've done this for a bit, and I've lost some weight, but I want to lose more. How do I do it?” Because I would agree with you that it's easy to alienate people unintentionally.

James O'Keefe: One thing I would say in defense of fasting is that, unlike almost any other dietary strategy, once you start doing some intermittent fasting of at least 12 hours or 14, 15 hours a day, it changes your hormones around. Your insulin levels are lower, your leptin sensitivity improves. And so, it's easier to stick with because you're not craving food all the time.

And I think that's the problem when you're eating the modern diet you're constantly hungry, because your hormones are all out of whack. And this is a great way to get the hormones back into optimal alignment.

Andrew Freeman: I think that's a good point, and I would say it certainly is a great thing when people start to take the things they take for granted, like eating, and they become more mindful about it in any form. I think that's a step in the right direction. So, that being said, we have a few more minutes left. Are there any other comments or tips that people would give to their patients this holiday season?

Monica Aggarwal: I thought of a good dessert that I really like around the holidays, which is chocolate-covered strawberries. Taking dark chocolate as the most unsweetened as you can get, which you can get a lot of neat ones, and then the sweet comes from the strawberry.

It's the most ridiculously easy thing to do. You can microwave your chocolate and dip it in. So, that's a really good, fun thing to bring to a party or to have at home every single night of holiday, if you'd like. Not that I do that or anything. But that's a nice treat.

Robert Ostfeld: Weaving in even more physical activity as possible, taking the stairs few extra times, etc. Now in the in the era of social distancing, going for walks with family throughout the day, as time allows, is a great way. Any way that you can weave in more physical activity as well.

Andrew Freeman: I think that's a really good point.

Emilio Ros: You can tell them how much they need to walk or run depending on which kind of dessert they had. A big sweet, they would have to walk for an hour to burn the calories. Maybe if they have some strawberries or some fruit, just for 5 minutes. This concept I think sometimes helps.

Andrew Freeman: Great. And I'll just add along with Monica's comments, if you go to some parts of our country in the United States, if you go to Los Angeles to the beach side of things, people wait in long lines for dark-chocolate-covered frozen bananas. If you haven't had one of those, they are surprisingly good.

Penny Margaret Kris-Etherton: Put nuts on them!

Andrew Freeman: Yes, you can get nuts on them! Now they've moved away from that. If you have been recently, you can add gummy bears and all sorts of awful things, but the plain original is certainly a great way to go.

Well, with that, I wanted to thank everyone for their time. We got some great input and some insights. I encourage you all as clinicians to really spend some time learning about nutrition, which is completely underrepresented in most of our studies and probably one of the most powerful tools in our arsenal. So, with that, I wish you a delicious and happy and healthy holiday season. And thanks so much for joining us.

Emilio Ros: Thank you. Take care during the holidays. Don't get too close to one another!