Giving a Voice to Patients With Smell Disorders Associated With COVID-19: Cross-Sectional Longitudinal Analysis Using Natural Language Processing of Self-Reports.

BACKGROUND: Smell disorders are commonly reported with COVID-19 infection. The smell-related issues associated with COVID-19 may be prolonged, even after the respiratory symptoms are resolved. These smell dysfunctions can range from anosmia (complete loss of smell) or hyposmia (reduced sense of smell) to parosmia (smells perceived differently) or phantosmia (smells perceived without an odor source being present). Similar to the difficulty that people experience when talking about their smell experiences, patients find it difficult to express or label the symptoms they experience, thereby complicating diagnosis. The complexity of these symptoms can be an additional burden for patients and health care providers and thus needs further investigation. OBJECTIVE: This study aims to explore the smell disorder concerns of patients and to provide an overview for each specific smell disorder by using the longitudinal survey conducted in 2020 by the Global Consortium for Chemosensory Research, an international research group that has been created ad hoc for studying chemosensory dysfunctions. We aimed to extend the existing knowledge on smell disorders related to COVID-19 by analyzing a large data set of self-reported descriptive comments by using methods from natural language processing. METHODS: We included self-reported data on the description of changes in smell provided by 1560 participants at 2 timepoints (second survey completed between 23 and 291 days). Text data from participants who still had smell disorders at the second timepoint (long-haulers) were compared with the text data of those who did not (non-long-haulers). Specifically, 3 aims were pursued in this study. The first aim was to classify smell disorders based on the participants' self-reports. The second aim was to classify the sentiment of each self-report by using a machine learning approach, and the third aim was to find particular food and nonfood keywords that were more salient among long-haulers than those among non-long-haulers. RESULTS: We found that parosmia (odds ratio [OR] 1.78, 95% CI 1.35-2.37; P<.001) as well as hyposmia (OR 1.74, 95% CI 1.34-2.26; P<.001) were more frequently reported in long-haulers than in non-long-haulers. Furthermore, a significant relationship was found between long-hauler status and sentiment of self-report (P<.001). Finally, we found specific keywords that were more typical for long-haulers than those for non-long-haulers, for example, fire, gas, wine, and vinegar. CONCLUSIONS: Our work shows consistent findings with those of previous studies, which indicate that self-reports, which can easily be extracted online, may offer valuable information to health care and understanding of smell disorders. At the same time, our study on self-reports provides new insights for future studies investigating smell disorders.

Appetite-regulating hormones modulate odor perception and odor-evoked activity in hypothalamus and olfactory cortices.

Odors guide food seeking, and food intake modulates olfactory function. This interaction is mediated by appetite-regulating hormones like ghrelin, insulin, and leptin, which alter activity in the rodent olfactory bulb, but their effects on downstream olfactory cortices have not yet been established in humans. The olfactory tract connects the olfactory bulb to the cortex through 3 main striae, terminating in the piriform cortex (PirC), amygdala (AMY), olfactory tubercule (OT), and anterior olfactory nucleus (AON). Here, we test the hypothesis that appetite-regulating hormones modulate olfactory processing in the endpoints of the olfactory tract and the hypothalamus. We collected odor-evoked functional magnetic resonance imaging (fMRI) responses and plasma levels of ghrelin, insulin, and leptin from human subjects (n = 25) after a standardized meal. We found that a hormonal composite measure, capturing variance relating positively to insulin and negatively to ghrelin, correlated inversely with odor intensity ratings and fMRI responses to odorized vs. clean air in the hypothalamus, OT, and AON. No significant correlations were found with activity in PirC or AMY, the endpoints of the lateral stria. Exploratory whole-brain analyses revealed significant correlations near the diagonal band of Broca and parahippocampal gyrus. These results demonstrate that high (low) blood plasma concentrations of insulin (ghrelin) decrease perceived odor intensity and odor-evoked activity in the cortical targets of the medial and intermediate striae of the olfactory tract, as well as the hypothalamus. These findings expand our understanding of the cortical mechanisms by which metabolic hormones in humans modulate olfactory processing after a meal.

Covid-19 affects taste independent of taste-smell confusions: results from a combined chemosensory home test and online survey from a large global cohort.

People often confuse smell loss with taste loss, so it is unclear how much gustatory function is reduced in patients self-reporting taste loss. Our pre-registered cross-sectional study design included an online survey in 12 languages with instructions for self-administering chemosensory tests with 10 household items. Between June 2020 and March 2021, 10,953 individuals participated. Of these, 5,225 self-reported a respiratory illness and were grouped based on their reported COVID test results: COVID-positive (COVID+, N = 3,356), COVID-negative (COVID-, N = 602), and COVID unknown for those waiting for a test result (COVID?, N = 1,267). The participants who reported no respiratory illness were grouped by symptoms: sudden smell/taste changes (STC, N = 4,445), other symptoms excluding smell or taste changes (OthS, N = 832), and no symptoms (NoS, N = 416). Taste, smell, and oral irritation intensities and self-assessed abilities were rated on visual analog scales. Compared to the NoS group, COVID+ was associated with a 21% reduction in taste (95% confidence interval (CI): 15-28%), 47% in smell (95% CI: 37-56%), and 17% in oral irritation (95% CI: 10-25%) intensity. There were medium to strong correlations between perceived intensities and self-reported abilities (r = 0.84 for smell, r = 0.68 for taste, and r = 0.37 for oral irritation). Our study demonstrates that COVID-19-positive individuals report taste dysfunction when self-tested with stimuli that have little to none olfactory components. Assessing the smell and taste intensity of household items is a promising, cost-effective screening tool that complements self-reports and may help to disentangle taste loss from smell loss. However, it does not replace standardized validated psychophysical tests.

Covid-19 affects taste independently of smell: results from a combined chemosensory home test and online survey from a global cohort (N=10,953).

People often confuse smell loss with taste loss, so it is unclear how much gustatory function is reduced in patients self-reporting taste loss. Our pre-registered cross-sectional study design included an online survey in 12 languages with instructions for self-administering chemosensory tests with ten household items. Between June 2020 and March 2021, 10,953 individuals participated. Of these, 3,356 self-reported a positive and 602 a negative COVID-19 diagnosis (COVID+ and COVID-, respectively); 1,267 were awaiting test results (COVID?). The rest reported no respiratory illness and were grouped by symptoms: sudden smell/taste changes (STC, N=4,445), other symptoms excluding smell or taste loss (OthS, N=832), and no symptoms (NoS, N=416). Taste, smell, and oral irritation intensities and self-assessed abilities were rated on visual analog scales. Compared to the NoS group, COVID+ was associated with a 21% reduction in taste (95% Confidence Interval (CI): 15-28%), 47% in smell (95%-CI: 37-56%), and 17% in oral irritation (95%-CI: 10-25%) intensity. In all groups, perceived intensity of smell (r=0.84), taste (r=0.68), and oral irritation (r=0.37) was correlated. Our findings suggest most reports of taste dysfunction with COVID-19 were genuine and not due to misinterpreting smell loss as taste loss (i.e., a classical taste-flavor confusion). Assessing smell and taste intensity of household items is a promising, cost-effective screening tool that complements self-reports and helps to disentangle taste loss from smell loss. However, it does not replace standardized validated psychophysical tests.

Body Fat Moderates the Association of Olfactory Dysfunction with Dietary Intake in U.S. Middle-Aged and Older Adults: A Cross-Sectional Analysis of NHANES 2013-2014.

Background: Obesity relates to impaired olfactory function. Abnormal olfactory function is also associated with poor diet; however, whether obesity-related markers shape this relationship is unknown. Methods: Cross-sectional analysis (n = 1415, age > 40 years) of NHANES 2013−2014 examined body fat percent (BF%) and waist circumference (WC) as moderators of the relationship between olfactory function and diet. The olfactory function test identified adults with olfactory dysfunction (OD) or normal olfaction (NO). Validated 24 h recall captured nutrient intake and Healthy Eating Index-2010 scores. BF% and WC were measured. We tested adjusted linear regression models, with an interaction term between olfactory function and BF%/WC, for each nutrient or HEI score, and reported coefficients (ß), standard errors (SE), and p-values for significant interaction terms. Results: In OD (9.5%; mean age 50.9 years, 95% CI 49.6, 52.2) compared with NO (mean age 49.3 years, 95% CI 48.8, 49.9), higher BF% was associated with higher intake of saturated fat (ß (SE): 0.2 (0.1) g; p = 0.06) and percent of total calories from total fat (0.2 (0.1); p = 0.07), saturated (0.1 (0.004); p = 0.02), and monounsaturated fat (0.1 (0.1); p = 0.08); lower percent of total calories from carbohydrates (−0.2 (0.1); p = 0.09) and mg of sodium (−17.8 (09.6); p = 0.08); and a higher (healthier) refined grain score (0.1 (0.1); p = 0.04). Higher WC was associated with higher refined grain scores (0.01 (0.02); p = 0.01) in OD. Conclusion: BF% may shape dietary intake and quality in OD. Longitudinal studies are needed to elucidate the directionality of these relationships and develop strategies to improve dietary intake among OD.

Self-reported Changes in Energy Balance Behaviors during COVID-19-related Home Confinement: A Cross-sectional Study.

Objectives: Cross-sectional reports on weight gain during the COVID-19 shelter-at-home have raised concerns for weight increases as the pandemic continues. We examined behaviors that impact energy intake and/or energy expenditure among adults in the United States during shelter-at-home. Methods: Cross-sectional data (N=1779; April 24 - May4, 2020) were collected on demographics, diet, physical activity, sleep, and food purchasing behaviors. Percent of participants reporting increase/ decrease/no change in these behaviors during the COVID-19 shelter-at-home were assessed. Each analysis was followed by comparing whether increases or decreases were more likely for each health behavior, in all participants and across sex (43.38% males). Results: Increased consumption of healthy foods, energy-dense unhealthy foods, and snacks, and increased sedentary activities (p < .001) was reported. Physical activity and alcohol intake declined (p < .001). Females were more likely than males (p < .001) to report ultra-processed foods/high-calorie snack intake, fruit/vegetable intake (p < .001) and increase (p < .01) sleep and sedentary behavior. Conclusion: Acute behavioral changes supporting greater energy intake and less energy expenditure, especially in females, underscore the significance of COVID-19-related increase in unstructured time. Longitudinal assessment of body weight and health behaviors is warranted to understand the impact of pandemic.

Olfactory perceptual decision-making is biased by motivational state.

Growing evidence suggests that internal factors influence how we perceive the world. However, it remains unclear whether and how motivational states, such as hunger and satiety, regulate perceptual decision-making in the olfactory domain. Here, we developed a novel behavioral task involving mixtures of food and nonfood odors (i.e., cinnamon bun and cedar; pizza and pine) to assess olfactory perceptual decision-making in humans. Participants completed the task before and after eating a meal that matched one of the food odors, allowing us to compare perception of meal-matched and non-matched odors across fasted and sated states. We found that participants were less likely to perceive meal-matched, but not non-matched, odors as food dominant in the sated state. Moreover, functional magnetic resonance imaging (fMRI) data revealed neural changes that paralleled these behavioral effects. Namely, odor-evoked fMRI responses in olfactory/limbic brain regions were altered after the meal, such that neural patterns for meal-matched odor pairs were less discriminable and less food-like than their non-matched counterparts. Our findings demonstrate that olfactory perceptual decision-making is biased by motivational state in an odor-specific manner and highlight a potential brain mechanism underlying this adaptive behavior.

Energy Balance-Related Behavior Risk Pattern and Its Correlates During COVID-19 Related Home Confinement.

Self-reported weight gain during the COVID-19 shelter-at-home has raised concerns for weight increases as the pandemic continues. We aimed to investigate the relationship of psychological and health markers with energy balance-related behaviors during the pandemic-related extended home confinement. Ratings for stress, boredom, cravings, sleep, self-control, and beliefs about weight control were collected from 1,609 adults using a questionnaire between April 24th-May 4th, 2020, while COVID-19 associated shelter-in-place guidelines were instituted across the US. We calculated four energy balance behavior scores (physical activity risk index, unhealthy eating risk index, healthy eating risk index, sedentary behavior index), and conducted a latent profile analysis of the risk factors. We examined psychological and health correlates of these risk patterns. Boredom, cravings for sweet/savory foods, and high sleepiness ratings related to high risk of increasing unhealthy eating and sedentary behavior and decreasing physical activity and healthy eating. Having greater self-control, control over cravings, or positive mood was related to lowering all aspects of energy intake and energy expenditure risks. Although individuals in risk pattern classes showed similarity in physical activity and healthy/unhealthy eating habits, they exhibited different patterns of positive mood, craving control, food cravings, boredom, and self-control. Psychological and health variables may have a significant role to play in risk behaviors associated with weight gain during the COVID-19 related home confinement. Emerging behavioral patterns may be meaningful in developing targeted weight management interventions during the current pandemic.

Reward-related neural correlates in adolescents with excess body weight.

The functional and connectivity reward processing in adults with excessive body weight is well documented, though is relatively less researched during adolescence. Given that reward and inhibition may be highly malleable during adolescence, it is unknown how impulsive behaviors, potentially stemming from impaired inhibitory control and heightened sensitivity to rewarding cues, relate to increases in body weight in adolescents. Adolescents (N = 76; mean age = 14.10 years, SD = 1.92) with varied body mass index (BMI) performed a child-friendly monetary incentive delay task during functional magnetic resonance imaging, to study reward processing during the anticipation of rewards (cue) and reactions to feedback about rewards (feedback). Our results show that adolescents with greater BMI z-score show neural activation and ventral striatum connectivity alterations in networks implicated in reward, salience detection, and inhibitory control. These bottom-up reward and top-down inhibitory control networks, as well as interactions between these networks were prevalent during the anticipation period (when the cue is presented) as well as when receiving feedback about whether one has received a reward. Specifically, our results were mainly driven by failure to receive a reward in the feedback period, and the anticipation of a potential reward in the anticipation period. Overall, we provide evidence for heightened reward salience as well as inhibitory control deficits that, in combination, may contribute to the impulsive behaviors that lead to higher BMI in adolescents.

Longitudinal Weight Gain and Related Risk Behaviors during the COVID-19 Pandemic in Adults in the US.

Cross-sectional analyses have shown increased obesogenic behaviors and a potential for weight gain during COVID-19 related peak-lockdown (March-May 2020), but longitudinal data are lacking. This study assessed longitudinal changes in body weight and lifestyle behaviors in the US adults during the pandemic. METHODS: We used Qualtrics survey to collect self-reported data on body weight, dietary, physical activity, and psychological variables (n = 727) during the peak-lockdown (April/May) and at post-lockdown (September/October). Peak-lockdown weight data were categorized based on the magnitude of weight gained, maintained, or lost, and behavioral differences were examined between categories at two time points. RESULTS: Body weight increased (+0.62 kg; p < 0.05) at the post-lockdown period. The body mass index also increased (26.38 ± 5.98 kg/m2 vs. 26.12 ± 5.81 kg/m2; p < 0.01) at the post-lockdown period vs. peak-lockdown period. Close to 40% of participants reported gaining either 1-4 lbs or >5 lbs of body weight during the peak-lockdown, while 18.2% lost weight. Weight-gainers engaged in riskier dietary behaviors such as frequent ultra-processed food intake (p < 0.01) and snacking (p < 0.001), were less active, and reported high stress and less craving control during peak-lockdown. Of those gaining >5 lbs, 33% continued to gain weight after the lockdown eased, while 28% maintain higher body weight. In weight-gainers, takeout meal frequency increased, and high ultra-processed food intake and stress, and low craving control continued to persist after the lockdown eased. CONCLUSION: We show that the COVID-19 lockdown periods disrupted weight management among many Americans and that associated health effects are likely to persist.

Self-weighing Practices and Associated Health Behaviors during COVID-19.

Objective: In this study, we investigated self-weighing frequency (SWF) among adults during the COVID-19 pandemic and retrospectively (6 months) before the pandemic, and whether SWF was associated with changes in health-related behaviors. Methods: United States adults (N = 1607) completed a health-related questionnaire during COVID-19 and associated shelter-in-place. We categorized respondents into 4 groups of SWF at the time of the pandemic: "Never," "< 1x a week," "1x a week," or "> 1x a week." Results: The proportion of adults never weighing increased during the pandemic (15% to 25%), whereas the proportion of those weighing < 1x week went down (41% to 29%). Higher SWF was significantly associated with changes in energy expenditure including increased total physical activity (PA), lower likelihood of decreases in vigorous, moderate, and walking PA, and a lower likelihood of sitting more. More frequent self-weighing also was associated statistically with lower likelihood of keeping unhealthy eating behaviors the same. Conversely, there was no significant difference in changes in alcohol, caffeine, takeout, fruit or vegetable consumption, and television viewing among SWF groups. Conclusion: SWF decreased during the pandemic in the lower 2 SWF categories. Higher SWF was associated with fewer negative changes in health behaviors, especially related to PA.

Recent Smell Loss Is the Best Predictor of COVID-19 Among Individuals With Recent Respiratory Symptoms.

In a preregistered, cross-sectional study, we investigated whether olfactory loss is a reliable predictor of COVID-19 using a crowdsourced questionnaire in 23 languages to assess symptoms in individuals self-reporting recent respiratory illness. We quantified changes in chemosensory abilities during the course of the respiratory illness using 0-100 visual analog scales (VAS) for participants reporting a positive (C19+; n = 4148) or negative (C19-; n = 546) COVID-19 laboratory test outcome. Logistic regression models identified univariate and multivariate predictors of COVID-19 status and post-COVID-19 olfactory recovery. Both C19+ and C19- groups exhibited smell loss, but it was significantly larger in C19+ participants (mean ± SD, C19+: -82.5 ± 27.2 points; C19-: -59.8 ± 37.7). Smell loss during illness was the best predictor of COVID-19 in both univariate and multivariate models (ROC AUC = 0.72). Additional variables provide negligible model improvement. VAS ratings of smell loss were more predictive than binary chemosensory yes/no-questions or other cardinal symptoms (e.g., fever). Olfactory recovery within 40 days of respiratory symptom onset was reported for ~50% of participants and was best predicted by time since respiratory symptom onset. We find that quantified smell loss is the best predictor of COVID-19 amongst those with symptoms of respiratory illness. To aid clinicians and contact tracers in identifying individuals with a high likelihood of having COVID-19, we propose a novel 0-10 scale to screen for recent olfactory loss, the ODoR-19. We find that numeric ratings ≤2 indicate high odds of symptomatic COVID-19 (4 < OR < 10). Once independently validated, this tool could be deployed when viral lab tests are impractical or unavailable.

Does the weight loss efficacy of alternate day fasting differ according to sex and menopausal status?

BACKGROUND AND AIMS: This study examined if the weight loss and metabolic benefits of alternate day fasting (ADF) varies according to sex and menopausal status in adults with obesity. METHODS AND RESULTS: This secondary analysis pooled the data of men and women (n = 75) who participated in three 12-week ADF studies (500 kcal fast day; alternated with an ad libitum intake feast day). Body weight decreased in premenopausal women (-4.6 ± 3.2%), postmenopausal women (-6.5 ± 3.2%) and men (-6.2 ± 4.4%) (main effect of time, P < 0.001), with no difference between groups (no group × time interaction). Energy intake on fast days was higher than prescribed in all groups (∼400-500 excess kcal consumed), with no differences between groups. Fat mass, lean mass, fasting insulin, and insulin resistance, and blood pressure decreased similarly in all groups (main effect of time, P < 0.05 for all comparisons). LDL cholesterol decreased more in postmenopausal versus premenopausal women (group × time interaction, P = 0.01). Fasting glucose, HDL cholesterol, and triglycerides remained unchanged in all groups. CONCLUSION: These findings suggest that the weight loss and metabolic benefits of ADF do not generally vary according to sex or menopausal status in adults with obesity. TRIAL REGISTRATION: Clinicaltrials.gov, NCT00960505; NCT03528317.

The best COVID-19 predictor is recent smell loss: a cross-sectional study.

BACKGROUND: COVID-19 has heterogeneous manifestations, though one of the most common symptoms is a sudden loss of smell (anosmia or hyposmia). We investigated whether olfactory loss is a reliable predictor of COVID-19. METHODS: This preregistered, cross-sectional study used a crowdsourced questionnaire in 23 languages to assess symptoms in individuals self-reporting recent respiratory illness. We quantified changes in chemosensory abilities during the course of the respiratory illness using 0-100 visual analog scales (VAS) for participants reporting a positive (C19+; n=4148) or negative (C19-; n=546) COVID-19 laboratory test outcome. Logistic regression models identified singular and cumulative predictors of COVID-19 status and post-COVID-19 olfactory recovery. RESULTS: Both C19+ and C19- groups exhibited smell loss, but it was significantly larger in C19+ participants (mean±SD, C19+: -82.5±27.2 points; C19-: -59.8±37.7). Smell loss during illness was the best predictor of COVID-19 in both single and cumulative feature models (ROC AUC=0.72), with additional features providing no significant model improvement. VAS ratings of smell loss were more predictive than binary chemosensory yes/no-questions or other cardinal symptoms, such as fever or cough. Olfactory recovery within 40 days was reported for ~50% of participants and was best predicted by time since illness onset. CONCLUSIONS: As smell loss is the best predictor of COVID-19, we developed the ODoR-19 tool, a 0-10 scale to screen for recent olfactory loss. Numeric ratings ≤2 indicate high odds of symptomatic COVID-19 (10

COVID-19 and the Chemical Senses: Supporting Players Take Center Stage.

The main neurological manifestation of COVID-19 is loss of smell or taste. The high incidence of smell loss without significant rhinorrhea or nasal congestion suggests that SARS-CoV-2 targets the chemical senses through mechanisms distinct from those used by endemic coronaviruses or other common cold-causing agents. Here we review recently developed hypotheses about how SARS-CoV-2 might alter the cells and circuits involved in chemosensory processing and thereby change perception. Given our limited understanding of SARS-CoV-2 pathogenesis, we propose future experiments to elucidate disease mechanisms and highlight the relevance of this ongoing work to understanding how the virus might alter brain function more broadly.

More Than Smell-COVID-19 Is Associated With Severe Impairment of Smell, Taste, and Chemesthesis.

Recent anecdotal and scientific reports have provided evidence of a link between COVID-19 and chemosensory impairments, such as anosmia. However, these reports have downplayed or failed to distinguish potential effects on taste, ignored chemesthesis, and generally lacked quantitative measurements. Here, we report the development, implementation, and initial results of a multilingual, international questionnaire to assess self-reported quantity and quality of perception in 3 distinct chemosensory modalities (smell, taste, and chemesthesis) before and during COVID-19. In the first 11 days after questionnaire launch, 4039 participants (2913 women, 1118 men, and 8 others, aged 19-79) reported a COVID-19 diagnosis either via laboratory tests or clinical assessment. Importantly, smell, taste, and chemesthetic function were each significantly reduced compared to their status before the disease. Difference scores (maximum possible change ±100) revealed a mean reduction of smell (-79.7 ± 28.7, mean ± standard deviation), taste (-69.0 ± 32.6), and chemesthetic (-37.3 ± 36.2) function during COVID-19. Qualitative changes in olfactory ability (parosmia and phantosmia) were relatively rare and correlated with smell loss. Importantly, perceived nasal obstruction did not account for smell loss. Furthermore, chemosensory impairments were similar between participants in the laboratory test and clinical assessment groups. These results show that COVID-19-associated chemosensory impairment is not limited to smell but also affects taste and chemesthesis. The multimodal impact of COVID-19 and the lack of perceived nasal obstruction suggest that severe acute respiratory syndrome coronavirus strain 2 (SARS-CoV-2) infection may disrupt sensory-neural mechanisms.

Corona Viruses and the Chemical Senses: Past, Present, and Future.

A wealth of rapidly evolving reports suggests that olfaction and taste disturbances may be manifestations of the novel COVID-19 pandemic. While otolaryngological societies worldwide have started to consider chemosensory evaluation as a screening tool for COVID-19 infection, the true nature of the relationship between the changes in chemosensory ability and COVID-19 is unclear. Our goal with this review is to provide a brief overview of published and archived literature, as well as the anecdotal reports and social trends related to this topic up to April 29, 2020. We also aim to draw parallels between the clinical/chemosensory symptomology reported in association to past coronavirus pandemics (such as SARS and MERS) and the novel COVID-19. This review also highlights current evidence on persistent chemosensory disturbances after the infection has resolved. Overall, our analysis pinpoints the need for further studies: 1) to better quantify olfaction and taste disturbances associated with SARS-CoV-2 infection, compared to those of other viral and respiratory infections, 2) to understand the relation between smell, taste, and chemesthesis disturbances in COVID-19, and 3) to understand how persistent are these disturbances after the infection has resolved.

Change in eating pattern as a contributor to energy intake and weight gain during the winter holiday period in obese adults.

BACKGROUND/OBJECTIVES: The winter holiday season in the United States, which spans mid-November to mid-January, contributes to over half of annual body weight gain. Although self-reported data have linked this weight change to both increased energy intake and reduced physical activity, objective techniques have never been used; and thus, the actual cause of holiday weight gain is controversial. Here, we aimed to determine changes in components of energy balance leading to the holiday weight gain. METHODS: Body weight change was compared between the pre-holiday (mid-September to mid-November) and the holiday period (mid-November to early January). Total energy expenditure (TEE) was measured using doubly labeled water during holiday time (early to mid-December). Subjective (ratings) and physiological (appetite-regulating hormones) measures of appetite, eating-away-from-home frequency, and incentive salience of food pictures were also evaluated. RESULTS: In 23 obese adults (87% female), body weight change during the holidays (0.41 ± 0.42 kg) was significantly higher (P = 0.02) than the body weight change during the pre-holiday period (-0.86 ± 0.42 kg). TEE was unchanged during the two periods, suggesting no role of energy expenditure on weight gain. However, participants reported lower satisfaction after a meal pre-load which was significantly correlated with increased body weight during the holiday period. An increase in number of episodes of eating at sit-down restaurants was also reported during that period. Overall, these changing behaviors were supported by a non-significant increase in energy intake (+80 kcal/day, P = 0.07) observed during the study holiday period. CONCLUSION: We conclude that a decrease in energy expenditure does not result in the weight increase, but that increase in food intake is the more likely cause. Our data imply that compromised internal satiety mechanisms in presence of external food cues and diet-related behavioral variables during the holidays may influence weight gain.