Abstract
This study assesses obesity, binge eating disorder, anorexia nervosa, and bulimia nervosa among sexual and gender minority children.
Obesity and eating disorders in youth are prevalent,1,2 are associated with medical and psychosocial consequences, and may persist into adulthood. Therefore, identifying subgroups of youth vulnerable to 1 or both conditions is critical. One group that may be at risk for obesity3 and disordered eating4 is sexual and gender minorities (SGM; those who identify as lesbian, gay, bisexual, and/or transgender or whose sexual orientation and/or gender identity/expression do not conform to societal conventions).
Although SGM identities may develop in childhood5 and early adolescence,6 many studies assess older adolescents and adults and rely on self-reported weight and eating pathology. Given the adverse sequelae of obesity and eating disorders, the identification of disparities among SGM youth has implications for clinical practice and public health.
Methods
Participants (aged 9-10 years) were derived from the Adolescent Brain Cognitive Development Study (https://abcdstudy.org/scientists/protocols/). Parents and children provided written consent and assent, respectively. Procedures for the current study were approved by Uniformed Services University institutional review board. Data were collected from September 2016 to August 2018.
Participants’ parents/guardians completed a demographic questionnaire, including family income and racial/ethnic identity. For the latter, parents/guardians selected the option(s) that best described their child. Height and weight were measured twice and averaged. Body mass index standardized scores were calculated using US Centers for Disease Control and Prevention growth standards adjusting for age and sex; scores of 1.64 or higher indicated presence of obesity.
Children were queried via computerized questionnaire: “Are you gay or bisexual?” and “Are you transgender?” Response options were yes, maybe, no, and “I do not understand this question.” In accordance with prior convention, youths responding yes or maybe to either item were coded as probable SGM.
A computerized semistructured diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School-Aged Children for Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) was administered to assess full-threshold and subthreshold (eg, other specified feeding or eating disorder) binge eating disorder, anorexia nervosa, and bulimia nervosa.
Outliers (<.2% of data points) were recoded to 3 SDs from the mean. Missing data (0.2%-1.3%) were handled using listwise deletion. Logistic regressions, adjusting for sex assigned at birth, age, race/ethnicity, and family income, were conducted to compare obesity and eating disorder prevalence by SGM status. IBM SPSS version 25.0 (IBM Corp) was used. Analysis began March 2020.
Results
There were 11 852 participants (mean [SD] age, 9.91 [0.62] years, 5672 [47.9%] female, 6094 [58.9%] non-Hispanic White) (Table 1). One in 6 youths (1987 [16.8%]) had obesity and 10.2% (n = 1188) had a full-threshold (86 [0.7%]) and/or subthreshold (1103 [9.4%]) eating disorder. The sample comprised 1.6% (n = 190) probable sexual (n = 151) and/or gender minority (n = 58) youths, of whom 24.7% (n = 47) responded yes and 75.3% (n = 143) responded maybe to the SGM queries. Adjusting for covariates, SGM youths were more likely to have obesity (odds ratio, 1.64; 95% CI, 1.09-2.48) and full-threshold or subthreshold binge eating disorder (odds ratio, 3.49; 95% CI, 1.39-8.76) (Table 2). SGM and non-SGM youths did not differ in the likelihood of full-threshold or subthreshold anorexia nervosa or bulimia nervosa. The same pattern of results remained when limiting SGM youths to those responding yes to the SGM items, although significance for the likelihood of obesity was attenuated.
Table 1. Participant Demographics by SGM Status.
| Characteristic | No. (%) | ||
|---|---|---|---|
| Total sample (N = 11 852) | SGM (n = 190) | Not SGM (n = 11 662) | |
| Age, mean (SD), y | 9.91 (0.62) | 9.90 (0.62) | 9.91 (0.62) |
| Female sex assigned at birth | 5672 (47.9) | 118 (62.1) | 5554 (47.6) |
| Race/ethnicity | |||
| White | 7504 (63.4) | 133 (70.0) | 7371 (63.3) |
| Black/African American | 1862 (15.7) | 21 (11.0) | 1841 (15.8) |
| Asian | 292 (2.5) | 3 (1.6) | 289 (2.5) |
| American Indian | 62 (0.5) | 1 (0.5) | 61 (0.5) |
| Pacific Islander | 16 (0.1) | 0 (0.0) | 16 (0.1) |
| Multiracial | 1412 (11.9) | 26 (13.7) | 1386 (11.9) |
| Other/unknown | 680 (5.8) | 6 (3.2) | 674 (5.8) |
| Hispanic/Latinx | 2403 (20.5) | 34 (18.2) | 2369 (20.6) |
| Family income, $ | |||
| ≤24 999 | 1627 (15.0) | 16 (9.3) | 1611 (15.1) |
| 25 000-49 999 | 1584 (14.6) | 29 (16.9) | 1555 (14.6) |
| 50 000-99 999 | 3067 (28.3) | 56 (32.6) | 3011 (28.2) |
| ≥100 000 | 4560 (42.1) | 71 (41.3) | 4489 (42.1) |
| BMIz score, mean (SD) | 0.42 (1.15) | 0.52 (1.21) | 0.42 (1.15) |
| Obesity status | 1987 (16.8) | 38 (20.1) | 1949 (16.8) |
| Subthreshold or full thresholda | |||
| Binge eating disorder | 134 (1.1) | 5 (2.6) | 129 (1.1) |
| Anorexia nervosa | 1034 (8.8) | 12 (6.3) | 1022 (8.9) |
| Bulimia nervosa | 21 (0.20) | 0 (0.0) | 21 (0.20) |
| Eating disorder (any) | 1188 (10.2) | 17 (8.9) | 1171 (10.2) |
Abbreviations: BMIz score, body mass index (calculated as weight in kilograms divided by height in meters squared) standardized score; SGM, sexual and/or gender minority.
Defined as condition, current condition in partial remission, or other specified feeding or eating disorder (does not meet full criteria for condition).
Table 2. Association of SGM Status With Obesity and Eating Disorders.
| Characteristic | OR (95% CI)a | ||||
|---|---|---|---|---|---|
| Obesity statusb | Subthreshold or full thresholdc | ||||
| Binge eating disorder | Anorexia nervosa | Bulimia nervosa | Eating disorder (any) | ||
| SGM status | 1.64 (1.09-2.48)d | 3.49 (1.39-8.76)e | 0.75 (0.39-1.43) | NA | 1.02 (0.59-1.74) |
| Sex | |||||
| Male | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Female | 0.93 (0.83-1.04) | 1.11 (0.75-1.63) | 0.91 (0.79-1.05) | 0.92 (0.33-2.53) | 0.93 (0.82-1.07) |
| Age | 0.99 (0.99-1.01) | 1.00 (0.98-1.03) | 0.99 (0.98-0.99)d | 0.98 (0.91-1.05) | 0.99 (0.98-0.99)d |
| Race | |||||
| Non-Hispanic White | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Otherf | 2.05 (1.80-2.33)g | 1.61 (1.03-2.51)d | 0.88 (0.74-1.03) | 7.46 (1.99-28.04)e | 0.98 (0.84-1.14) |
| Family income | 0.71 (0.67-0.75)g | 0.68 (0.56-0.82)g | 1.08 (0.99-1.16) | 1.22 (0.76-1.96) | 1.01 (0.94-1.09) |
Abbreviations: NA, not applicable; OR, odds ratio; SGM, sexual and/or gender minority.
Test conducted: logistic regression.
Obesity status defined as body mass index (calculated as weight in kilograms divided by height in meters squared) standardized score ≥1.64.
Defined as: condition, current condition in partial remission, or other specified feeding or eating disorder (does not meet full criteria for condition).
P < .05.
P < .01.
Other includes Black, Asian, American Indian, Pacific Islander, multiracial, and other/unknown.
P < .001.
Discussion
SGM youths were more likely to have obesity and full-threshold or subthreshold binge eating disorder compared with non-SGM peers. There were no differences in the likelihood of anorexia nervosa nor bulimia nervosa. Limitations include the possibility that SGM identities are not well-established during this period and, rather, continue to evolve in adolescence.6 Furthermore, eating disorders were not assessed with a specialized interview, Avoidant/Restrictive Food Intake Disorder (an age-relevant disorder) was not captured, and some eating disorder diagnoses had small cell counts. Findings suggest that weight3 and eating disorder4 disparities observed in SGM adolescents/adults may emerge in childhood; clinicians should consider assessing eating- and health-related behaviors among SGM youths. Prospective research with larger samples of SGM youths is needed to elucidate the mechanisms contributing to observed health disparities.
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