Abstract
Objectives. We examined purging for weight control, diet pill use, and obesity across sexual orientation identity and ethnicity groups.
Methods. Anonymous survey data were analyzed from 24 591 high school students of diverse ethnicities in the federal Youth Risk Behavioral Surveillance System Survey in 2005 and 2007. Self-reported data were gathered on gender, ethnicity, sexual orientation identity, height, weight, and purging and diet pill use in the past 30 days. We used multivariable logistic regression to estimate odds of purging, diet pill use, and obesity associated with sexual orientation identity in gender-stratified models and examined for the presence of interactions between ethnicity and sexual orientation.
Results. Lesbian, gay, and bisexual (LGB) identity was associated with substantially elevated odds of purging and diet pill use in both girls and boys (odds ratios [OR] range = 1.9–6.8). Bisexual girls and boys were also at elevated odds of obesity compared to same-gender heterosexuals (OR = 2.3 and 2.1, respectively).
Conclusions. Interventions to reduce eating disorders and obesity that are appropriate for LGB youths of diverse ethnicities are urgently needed.
The prevalence of childhood obesity has markedly increased in the past few decades, more than tripling in the last 30 years.1 Obesity in adolescence is especially concerning because of the high risk of immediate- and long-term problems associated with the condition. Obese adolescents are at an elevated risk for high cholesterol, hypertension, prediabetes, bone and joint problems, and sleep apnea.2−5 They are 20 times more likely to become obese adults,6 increasing the odds of long-term health consequences secondary to obesity, such as type 2 diabetes, heart disease, stroke, cancer, and osteoarthritis.7 Eating disorders and disordered weight-control behaviors, such as purging and diet pill use, represent the third most common chronic childhood illnesses, after obesity and asthma,8 and are associated with a range of serious comorbidities, including disorders of the cardiovascular, gastrointestinal, and endocrine systems.9 In addition, children and adolescents who are obese have been found to be at increased risk of eating disorder symptoms.10−12
These health problems affect individuals during crucial physiological and psychological developmental periods and disproportionately affect marginalized subgroups of youths. Numerous studies have highlighted disparities based on ethnicity,13−17 sexual orientation,18−22 and gender.23−26 However, little is known about how these disparities intersect and the ways in which individuals who are members of multiple minority subgroups may be affected.
Minority stress theory posits that members of marginalized social populations are subject to health consequences as a result of experiences of stigma and discrimination associated with possessing a minority identity.27 These stressors may have direct health consequences through chronic perturbations of biological systems or may cause psychological distress, influencing health behaviors (substance use, weight-control behaviors, sexual risk behaviors, etc.) and health care utilization. Multiple minority stress theory focuses on the intersection of ethnicity, gender, and sexual orientation and proposes that lesbian, gay, and bisexual (LGB) people of color are exposed to multiple stressors that may create an additive health disadvantage.28,29 Several population-based studies have supported the additive hypothesis, demonstrating increased prevalence of health risks among LGB people of color compared with their White LGB counterparts, including disparities in mental health disorders,30,31 chronic health conditions,32 adolescent suicide,33 and obesity.34
The additive hypothesis of minority stress theory, however, has been scrutinized because it has not been consistently borne out. For example, other studies35,36 found that ethnicity did not modify sexual orientation–related health disparities, and 1 study29 found that being a member of a ethnic minority group had some protective effect on mental health among LGB individuals, specifically for adolescent girls.
We found a limited number of studies that addressed health disparities affecting LGB people of color and an even smaller number of studies that addressed adolescents and young adults.29,33,35−37 In addition, no studies, to our knowledge, specifically examined the issue of disordered weight-control behaviors. We were aware of only 1 study that examined the prevalence of obesity among sexual minorities as associated with ethnicity; this study found that Asian Pacific Islanders had lower body mass index (BMI) and African Americans had higher BMI in a sample of lesbian and bisexual women compared with White women.34 The aim of the present study examined how gender and ethnicity were associated with sexual orientation identity disparities in obesity and disordered weight-control behaviors in youths using data from the Youth Risk Behavior Surveillance System (YRBSS), a biennial survey conducted by the Centers for Disease Control and Prevention (CDC) in US high schools. This study was unique in its focus on disordered weight-control behaviors and obesity, 2 important adolescent health issues in LGB ethnic minority youths, who are an understudied population.
METHODS
For the present study, we pooled anonymous data gathered from US high school students in 2005 and 2007 as part of the YRBSS. Four cities (Boston, Massachusetts; Chicago, Illinois; New York City, New York; and San Francisco, California) and 5 states (Delaware, Maine, Massachusetts, Vermont, and Rhode Island) administered an item on sexual orientation identity; therefore, for the present study, we analyzed data from these jurisdictions. More details about the pooling methods used and the characteristics of jurisdictions included in analyses can be found elsewhere.38
Measures
Students in participating high schools completed self-report surveys assessing sexual orientation identity, demographic characteristics, and health-related behaviors and exposures. An item assessing sexual orientation identity asked students to indicate which identity best described them from the options heterosexual, bisexual, lesbian or gay, or unsure.
Outcomes included purging for weight control, use of diet pills, and obesity. The YRBSS survey includes 1 item asking whether respondents engaged in self-induced vomiting or used laxatives (i.e., purging) in the past 30 days and another item asking whether they used diet pills without a doctor’s orders to lose or maintain weight.39 Each item was treated as binary. Students were asked to report their height and weight, which was then used to calculate age- and sex-specific BMI (defined as weight in kilograms divided by the square of height in meters) percentiles based on CDC guidelines; biologically implausible BMI values were also identified and set to missing per CDC guidelines.40 Youths were then categorized as obese if their BMI was at or above the 95th percentile for their age and gender. It was shown that self-reported BMI had moderate validity in adolescents.41
Statistical Analysis
All descriptive analyses were carried out with SPSS (version 20; SPSS Inc, Chicago, IL), and multilevel software HLM (version 7; Scientific Software International, Lincolnwood, IL) was used to fit final multivariable models. Gender-stratified multivariable logistic regression models were used to estimate the odds of each of the 3 outcome variables (purging, diet pill use, and obesity) associated with sexual orientation identity and ethnicity, controlling for age, region, and data collection wave. Heterosexual youths served as the referent group for sexual orientation group comparisons, and White youths for ethnicity group comparisons. In additional multivariable models, we examined whether ethnicity modified associations between sexual orientation identity and the 3 outcomes by entering interaction terms into the models.
The YRBSS complex sampling design was accounted for by adjusting the relative weights and altering the effective sample size for each jurisdiction (i.e., city or state). Because data were clustered, hierarchical linear modeling was done with jurisdiction assigned at level 2 in each model. See Mustanski et al.38 for additional information about methods used to calculate design effects and to account for intracluster correlation.
Surveys received from 28 887 youths were combined across the 9 jurisdictions and 2 waves of collection. Students were excluded if they did not provide important information for analyses (i.e., were missing covariates or outcome variables), leading to a final analytic sample of 24 591 youths (85.1% of original sample).
RESULTS
Table 1 presents selected sociodemographic characteristics of the ethnically diverse youths included in analyses. Among girls, those identifying as a sexual minority made up more than 8% of the analytic sample, and among boys, sexual minorities made up almost 5% of the analytic sample. Mean age was 15.9 years (SD = 1.3; range = 13–18 years).
TABLE 1—
Sample Characteristics of US High School Students: Youth Risk Behavioral Surveillance System Survey, 2005 and 2007
| Characteristics | No. (%) |
| Girls (n = 12 132) | |
| Ethnicity | |
| Asian-American | 1357 (11.2) |
| African-American | 3218 (26.5) |
| Latina | 2222 (18.3) |
| Other ethnicityb | 1114 (9.2) |
| White (Ref) | 4221 (34.8) |
| Sexual orientation identity | |
| Lesbian | 137 (1.1) |
| Bisexual | 628 (5.2) |
| Unsure | 303 (2.5) |
| Heterosexual (Ref) | 11 064 (91.2) |
| Boys (n = 12 459) | |
| Ethnicity | |
| Asian-American | 1714 (13.8) |
| African-American | 2906 (23.3) |
| Latino | 2220 (17.8) |
| Other ethnicitya | 1046 (8.4) |
| White (Ref) | 4573 (36.7) |
| Sexual orientation identity | |
| Gay | 149 (1.2) |
| Bisexual | 221 (1.8) |
| Unsure | 268 (2.2) |
| Heterosexual (Ref) | 11 821 (94.9) |
Note. The maximum sample size was n = 24 591.
Other ethnicity group includes youths who identified as Pacific Islander, American Indian, Alaskan Native, or multiple ethnicity groups.
The percentage of youths engaging in purging and diet pill use are presented in Table 2 for each gender, ethnicity, and sexual orientation identity group. In general, a higher percentage of sexual minorities within each ethnicity group reported purging and use of diet pills than did heterosexuals among both girls and boys. Within some groups, as much as a one quarter to more than one third of sexual minorities reported purging or diet pill use to control weight in the past 30 days, compared with a mean of approximately 8% of heterosexual girls and 5% of heterosexual boys across ethnicity groups. Table 2 also presents the percentages of obesity for each gender, ethnicity, and sexual orientation identity group. Among girls who were not Asian American, the percentage of obesity in heterosexuals ranged from 6% to 12% across ethnicity groups, whereas this percentage in sexual minorities ranged widely from 4% to 27%. Among boys, the percentage of obesity in bisexuals was especially elevated, ranging from 20% to 50% in Latinos, Whites, and other ethnicity groups compared with a mean of approximately 15% among heterosexuals in these groups. Asian Americans had a lower percentage of obesity compared with other ethnicity groups among both girls and boys.
TABLE 2—
Prevalence of Purging (Vomiting or Laxatives), Diet Pill Use, and Obesity in US High School Students: Youth Risk Behavioral Surveillance System Survey, 2005 and 2007
| Characteristics | Total, No. (%) | Purge,a % | Diet Pills,a % | Obese,b % |
| Girls (n = 12 132) | ||||
| Asian-American | ||||
| Lesbian | 12 (0.9) | …c | …c | 0 |
| Bisexual | 33 (2.4) | 13.9 | 11.8 | 0 |
| Unsure | 52 (3.8) | 5.7 | 8.9 | 0 |
| Heterosexual | 1260 (92.9) | 3.0 | 1.9 | 2.3 |
| African-American | ||||
| Lesbian | 52 (1.6) | 15.2 | 1.4 | 19.2 |
| Bisexual | 156 (4.8) | 6.3 | 6.7 | 26.9 |
| Unsure | 62 (1.9) | 24.2 | 8.5 | 12.9 |
| Heterosexual | 2948 (91.6) | 3.5 | 2.8 | 12.2 |
| Latina | ||||
| Lesbian | 22 (1.0) | 26.7 | 44.7 | 4.5 |
| Bisexual | 124 (5.6) | 15.1 | 9.1 | 16.9 |
| Unsure | 46 (2.2) | 8.2 | 10.1 | 15.2 |
| Heterosexual | 2030 (91.5) | 6.4 | 4.0 | 9.1 |
| Other ethnicityd | ||||
| Lesbian | 28 (2.5) | 18.8 | 0 | 16.7 |
| Bisexual | 88 (7.9) | 13.4 | 11.5 | 11.4 |
| Unsure | 50 (4.5) | 22.2 | 3.3 | 14.0 |
| Heterosexual | 948 (85.1) | 6.1 | 4.9 | 11.2 |
| White | ||||
| Lesbian | 23 (0.5) | 15.2 | 18.4 | 13.0 |
| Bisexual | 227 (5.4) | 18.6 | 14.2 | 14.5 |
| Unsure | 93 (2.2) | 8.3 | 6.9 | 9.7 |
| Heterosexual | 3878 (91.9) | 6.1 | 5.1 | 5.6 |
| Boys (n = 12 459) | ||||
| Asian-American | ||||
| Gay | 14 (0.8) | …c | …c | 7.1 |
| Bisexual | 29 (1.7) | 18.9 | 21.1 | 10.3 |
| Unsure | 89 (5.2) | 9.1 | 1.4 | 5.6 |
| Heterosexual | 1582 (92.3) | 2.1 | 2.9 | 9.3 |
| African-American | ||||
| Gay | 39 (1.3) | 14.6 | 17.7 | 5.1 |
| Bisexual | 51 (1.8) | 35.3 | 41.9 | 15.7 |
| Unsure | 52 (1.8) | 7.2 | 6.5 | 13.5 |
| Heterosexual | 2764 (95.1) | 4.8 | 3.5 | 14.8 |
| Latino | ||||
| Gay | 32 (1.4) | 12.4 | 6.5 | 21.9 |
| Bisexual | 36 (1.6) | 7.8 | 5.8 | 50.0 |
| Unsure | 24 (1.1) | 17.8 | 29.6 | 25.0 |
| Heterosexual | 2128 (95.9) | 2.8 | 4.1 | 18.1 |
| Other ethnicityd | ||||
| Gay | 21 (2.0) | 22.2 | 23.1 | 23.8 |
| Bisexual | 29 (2.8) | 30.4 | 20.0 | 48.3 |
| Unsure | 30 (2.9) | 10.3 | 30.4 | 16.7 |
| Heterosexual | 966 (92.4) | 3.7 | 4.2 | 16.6 |
| White | ||||
| Gay | 43 (0.9) | 16.2 | 12.8 | 11.6 |
| Bisexual | 76 (1.7) | 13.6 | 11.4 | 19.7 |
| Unsure | 73 (1.6) | 11.1 | 9.0 | 22.9 |
| Heterosexual | 4381 (95.8) | 2.1 | 2.9 | 13.7 |
Note. The maximum sample size was n = 24 591.
Purging defined as any vomiting or use of laxatives in the past month to control weight; diet pill use defined as use of diet pills to control weight without a doctor’s prescription in the past month.
Obesity defined as body mass index three quarters of 95th percentile for age and sex as per percentile definitions based on guidelines from the US Centers for Disease Control and Prevention.
Fewer than 10 participants responded in this category; therefore, data are not presented.
Other ethnicity group includes youths who identified as Pacific Islander, American Indian, Alaskan Native, or multiple ethnicity groups.
Multivariable models were fit to examine main effects for sexual orientation identity and ethnicity on eating disorder symptoms and obesity and to examine for possible interaction effects. Ethnicity did not modify sexual orientation identity associations with outcomes; therefore, results of main effects models are presented in the following and in Table 3. Sizable sexual orientation disparities in eating disorder symptoms in both girls and boys were observed. Sexual minority girls had 2 to 4 times the odds of purging and diet pill use compared with heterosexual peers, and sexual minority boys had 3 to approximately 7 times the odds of these behaviors compared with heterosexual peers. Compared with White same-gender peers, Asian American and African American girls had lower odds of purging and diet pill use, whereas African American boys had higher odds of purging, and other ethnicity boys had higher odds of both purging and diet pill use.
TABLE 3—
Odds of Purging, Diet Pill Use, and Obesity Associated With Ethnicity and Sexual Orientation Identity in US High School Students: Youth Risk Behavioral Surveillance System Survey, 2005 and 2007
| Purging,a OR (95% CI) | Diet Pill Use,a OR (95% CI) | Obese,b OR (95% CI) | |
| Girls | |||
| Age, y | 1.02 (0.96, 1.10) | 1.16* (1.07, 1.26) | 0.99 (0.93, 1.05) |
| Ethnicity | |||
| Asian-American | 0.42* (0.27, 0.65) | 0.46* (0.27, 0.79) | 0.45* (0.29, 0.68) |
| African-American | 0.59* (0.45, 0.77) | 0.58* (0.43, 0.80) | 2.59* (2.14, 3.14) |
| Latina | 0.92 (0.79, 1.20) | 0.89 (0.65, 1.22) | 1.90* (1.51, 2.41) |
| Other ethnicityc | 0.93 (0.72, 1.21) | 0.94 (0.67, 1.32) | 2.16* (1.73, 2.70) |
| White (Ref) | 1.0 | 1.0 | 1.0 |
| Sexual orientation identity | |||
| Lesbian | 3.95* (2.26, 6.89) | 4.00* (2.11, 7.58) | 1.50 (0.81, 2.76) |
| Bisexual | 3.23* (2.52, 4.16) | 3.06* (2.29, 4.11) | 2.25* (1.75, 2.88) |
| Unsure | 2.55* (1.77, 3.73) | 1.91* (1.09, 3.35) | 1.41 (0.88, 2.24) |
| Heterosexual (Ref) | 1.0 | 1.0 | 1.0 |
| Boys | |||
| Age, y | 1.04 (0.97, 1.11) | 1.15 (1.05, 1.27) | 0.97 (0.93, 1.01) |
| Ethnicity | |||
| Asian-American | 0.77 (0.52, 1.14) | 0.84 (0.51, 1.39) | 0.66* (0.53, 0.83) |
| African-American | 1.60* (1.26, 2.03) | 1.16 (0.84, 1.61) | 1.16 (0.98, 1.36) |
| Latino | 1.28 (0.96, 1.70) | 1.21 (0.84, 1.75) | 1.61* (1.35, 1.91) |
| Other ethnicityc | 1.54* (1.19, 2.01) | 1.49* (1.06, 2.09) | 1.41* (1.18, 1.68) |
| White (Ref) | 1.0 | 1.0 | 1.0 |
| Sexual orientation identity | |||
| Gay | 5.21* (3.47, 7.82) | 4.33* (2.72, 6.91) | 0.87 (0.53, 1.41) |
| Bisexual | 6.16* (4.09, 9.26) | 6.77* (4.20,10.91) | 2.10* (1.43, 3.07) |
| Unsure | 3.76* (2.51, 5.65) | 3.00* (1.71, 5.29) | 1.21 (0.84, 1.74) |
| Heterosexual (Ref) | 1.0 | 1.0 | 1.0 |
Note. CI =confidence interval; OR = odds ratio. Models are gender-stratified and control for age, ethnicity, sexual orientation, region, and data collection wave. The maximum sample size was n = 24 591.
Purging defined as any vomiting or use of laxatives in the past month to control weight; diet pill use defined as use of diet pills to control weight without a doctor’s prescription in the past month.
Obese defined as body mass index of three quarters of 95th percentile for age and sex based on guidelines from the US Centers for Disease Control and Prevention.
Other ethnicity group includes youths who identified as Pacific Islander, American Indian, Alaskan Native, or multiple ethnicity groups.
*P < .05.
Sexual orientation identity disparities were also observed for obesity. Bisexual girls and boys had higher odds of obesity compared with same-gender heterosexual peers. Although Asian Americans had lower odds of obesity compared with White youths, all other youths of color, with the exception of African American boys, had higher odds of obesity than their same-gender White peers.
DISCUSSION
Obesity and eating disorders in adolescence put young people at risk for a myriad of immediate- and long-term health problems associated with significant morbidity, disability, medical costs, and increased risk of premature death.9,42−45 Identifying groups at elevated risk is essential to informing an effective and appropriately targeted public health response to the health burden posed by these conditions.
Findings from our study of US high school students of diverse ethnicities indicated that both female and male sexual minorities of all ethnic groups were at substantially elevated risk of disordered weight-control behaviors, in some cases as much as a 7-fold increased risk. Across ethnicity groups, as many as 1 in 3 lesbian and bisexual girls engaged in these behaviors in the past month compared with fewer than 1 in 10 heterosexual girls. Similarly, across ethnicity groups, 1 in 5 gay and bisexual boys reported disordered weight-control behaviors in the past month compared with 1 in 20 heterosexual boys. Rates of obesity were elevated in female and male bisexuals compared with their same-gender heterosexual peers.
Our findings of elevated rates of disordered weight-control behaviors among sexual minority adolescents were consistent with those from previous research.19,21,22 Previous statewide surveys in Massachusetts and Minnesota found gay and bisexual adolescent boys had high rates of these behaviors46,47 compared with heterosexual boys, as was also found in the Growing Up Today Study, a nationwide cohort of predominantly White youths.19 The present study added to the literature by documenting patterns of elevated risk in sexual minority boys of diverse ethnicities living across the United States. In addition, the present study added to previous studies on adolescent girls,19,22 by providing clear evidence that purging for weight control and diet pill use were highly prevalent among sexual minority girls of diverse ethnicities.
In relation to ethnicity, our study suggested that African American female adolescents might have some protection against engaging in vomiting or abuse of laxatives or diet pills to control weight. Previous studies showed mixed results on this point, with some finding a similar protective effect,17,48 whereas others did not find reduced risk.15,21,49 Our study also suggested that Asian American girls might be at decreased risk for disordered weight-control behaviors compared with Whites, consistent with previous findings from the National Latino and Asian American Study.50 Among ethnic minority boys, our findings were consistent with previous research that showed Latino and African American boys had higher rates of disordered weight-control behaviors compared with White boys.16,49 This trend was not found among Asian American boys, which was consistent with previous literature.50
Few studies have examined associations of sexual orientation with obesity in adolescents. One previous study with youths participating in the Growing Up Today Study, a cohort made up predominantly of White youths, demonstrated that sexual orientation minority girls had a higher BMI than heterosexual girls, whereas among boys the reverse was found, with heterosexual boys having higher BMI than gay boys.18 For girls, the present findings differed from the previous study, in that elevated odds of obesity were found only for bisexuals and not lesbians. For boys, results from the present study also differed from previous findings, in that gay boys did not differ from heterosexuals, whereas bisexual boys had 2 times the odds of obesity compared with heterosexual peers.
A number of studies have shown elevated rates of obesity among ethnic minority adolescents,13−17 especially in African American and Latina girls compared with their White same-gender peers. Our findings were consistent with these studies, demonstrating an increased notable risk of obesity among African American and Latina girls. Our results were also consistent with those of previous research, which found Asian Americans youths were at lower risk of obesity compared with White youths.14,51
The present study did not find support for the additive hypothesis of multiple minority stress theory, as sexual orientation-by-ethnicity interactions were not found to be significant in multivariable regression models. This null finding might have been because of insufficient statistical power; however, prevalence estimates for outcomes presented in Table 2 did not suggest any consistent patterns of additivity. Contemporary approaches to intersectionality research recommend studying the risk associated with the unique experiences of being LGB people of color (e.g., the experience of being Asian American, bisexual, and female), rather than assuming that the experience was merely the sum of the risk of being a sexual minority in addition to an ethnic minority.52−54 Such research requires collecting data on the processes and contexts that generate unique risks and protections for individuals with LGB people of color identities. For example, a few studies found that gay and bisexual males who were an ethnic minority, especially Latino, might be at particularly elevated risk for mental health problems because of family rejection.28,37,55
Limitations
Our study had several limitations that should be considered. Although our analytic sample was very large, we still might not have had sufficient statistical power to detect sexual-orientation-by-ethnicity interactions or to detect a possible modest increased odds of obesity for lesbians compared with heterosexual peers. Generalizability of findings was limited to the jurisdictions across the country that provided data. Our findings relied on self-reported height and weight. Studies showed that although self-reported height and weight are highly correlated with measured height and weight, adolescents tend to overreport their height and underreport their weight. In particular, some studies found that males and non-Hispanic Whites were more likely to overreport height and females were more likely to underreport weight.39,56,57 Importantly, another study of adolescents and young adults found no evidence that sexual orientation modified bias in self-reported BMI among females, although gay males were found to underreport BMI to a greater degree than were heterosexual males.58 The YRBSS provided little information on important factors that might help to explain disparities in disordered weight-control behaviors and obesity, such as socioeconomic status, harassment and violence victimization, respondents’ family and social environment, and psychological health.8,59,60 The use of identity to classify sexual orientation hindered our ability to examine the subset of sexual minorities who had same- or both-gender attractions or sexual partners but did not identify as bisexual, gay, or lesbian. The YRBSS did not assess several important indicators of eating disorders, such as fasting and psychological symptoms; therefore, our analyses likely underestimated the prevalence of eating disorder symptoms in the population. Our dichotomous measures of any purging and diet pill use in the past 30 days did not allow us to examine symptom severity, which also might differ by sexual orientation identity and ethnicity.
Conclusions
Eating disorders and obesity are serious conditions with short- and long-term implications for comorbid disease risk, medical and psychiatric treatment costs, quality of life, and longevity.9,42−45 In the present study, sizable disparities in disordered weight control behaviors adversely affecting all sexual minority groups of both genders were found for self-induced vomiting and abuse of laxatives and diet pills. Because of minimal regulation on the sale of laxatives and diet pills in the United States,61 vulnerable and marginalized youths, such as sexual minorities and others, have largely unfettered access to purchase these products, which are then too often abused in dangerous attempts to control weight. As done with regard to other abused substances, such as alcohol and tobacco, public health professionals and policymakers need to step up efforts to protect minors from industries that currently profit from the abuse of their products by vulnerable youths.61 The findings of the present study also highlighted the serious issue of obesity in female and male bisexual youths. Obesity in adolescence is strongly associated with a myriad immediate- and long-term adverse consequences.6,7 Health and other professionals working with sexual minority youths need to establish mechanisms to screen for symptoms of eating disorders so that affected youths can be referred for treatment and need to develop programs to promote healthful weight-control behaviors in sexual minorities of all ethnicities and in both girls and boys. In addition, interventions that are appropriate for sexual orientation minority youths of diverse ethnicities are urgently needed to eliminate stressors and other factors contributing to these disparities.
Acknowledgments
This project was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Award Number R21HD051178) and by the IMPACT LGBT Health and Development Program at Northwestern University. Assistance from the Centers for Disease Control and Prevention (CDC) Division of Adolescent and School Health and the work of the state and local health and education departments who conduct the Youth Risk Behavior Surveys made the project possible. S. B. Austin is supported by the Leadership Education in Adolescent Health project, Maternal and Child Health Bureau (HRSA grant 6T71-MC00009). J. P. Calzo is supported by National Research Service Award F32HD066792, and B. Everett is supported by grant R03 HD062597, both from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
The authors would like to thank Annabel Chang for her help with preparing the article, and the thousands of students and school staff across the country who made this study possible.
Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the CDC, or any agencies involved in collecting the data.
Human Participant Protection
Protocol approval was not necessary because de-identified data were obtained from secondary sources. Data use agreements were obtained from Vermont Department of Health and the Rhode Island Department of Health, which were the only 2 state departments of health that required these agreements for access to Youth Risk Behavior Surveillance System data.
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