This cross-sectional study investigates if there are differences in the cumulative cardiovascular health scores between sexual minority and heterosexual adults.
Key Points
Question
Are there differences in cumulative cardiovascular health (CVH) scores between sexual minority and heterosexual adults?
Findings
In this cross-sectional analysis of data from 12 180 participants in the National Health and Nutrition Examination Survey (2007-2016), bisexual female individuals had lower CVH scores compared with heterosexual female individuals, which was primarily attributed to nicotine exposure and higher body mass index. No differences in cumulative CVH were found between other groups of sexual minority adults and their heterosexual peers.
Meaning
Results suggest that there is a need for tailored interventions to improve the CVH of sexual minority individuals, particularly bisexual female individuals.
Abstract
Importance
Research on the cardiovascular health (CVH) of sexual minority adults has primarily examined differences in the prevalence of individual CVH metrics rather than comprehensive measures, which has limited development of behavioral interventions.
Objective
To investigate sexual identity differences in CVH, measured using the American Heart Association’s revised measure of ideal CVH, among adults in the US.
Design, Setting, and Participants
This cross-sectional study analyzed population-based data from the National Health and Nutrition Examination Survey (NHANES; 2007-2016) in June 2022. Participants included noninstitutional adults aged 18 to 59 years. We excluded individuals who were pregnant at the time of their interview and those with a history of atherosclerotic cardiovascular disease or heart failure.
Exposures
Self-identified sexual identity categorized as heterosexual, gay/lesbian, bisexual, or something else.
Main Outcomes and Measures
The main outcome was ideal CVH (assessed using questionnaire, dietary, and physical examination data). Participants received a score from 0 to 100 for each CVH metric, with higher scores indicating a more favorable CVH profile. An unweighted average was calculated to determine cumulative CVH (range, 0-100), which was recoded as low, moderate, or high. Sex-stratified regression models were performed to examine sexual identity differences in CVH metrics, disease awareness, and medication use.
Results
The sample included 12 180 participants (mean [SD] age, 39.6 [11.7] years; 6147 male individuals [50.5%]). Lesbian (B = −17.21; 95% CI, −31.98 to −2.44) and bisexual (B = −13.76; 95% CI, −20.54 to −6.99) female individuals had less favorable nicotine scores than heterosexual female individuals. Bisexual female individuals had less favorable body mass index scores (B = −7.47; 95% CI, −12.89 to −1.97) and lower cumulative ideal CVH scores (B = −2.59; 95% CI, −4.84 to −0.33) than heterosexual female individuals. Compared with heterosexual male individuals, gay male individuals had less favorable nicotine scores (B = −11.43; 95% CI, −21.87 to −0.99) but more favorable diet (B = 9.65; 95% CI, 2.38-16.92), body mass index (B = 9.75; 95% CI, 1.25-18.25), and glycemic status scores (B = 5.28; 95% CI, 0.59-9.97). Bisexual male individuals were twice as likely as heterosexual male individuals to report a diagnosis of hypertension (adjusted odds ratio [aOR], 1.98; 95% CI, 1.10-3.56) and use of antihypertensive medication (aOR, 2.20; 95% CI, 1.12-4.32). No differences in CVH were found between participants who reported their sexual identity as something else and heterosexual participants.
Conclusion and Relevance
Results of this cross-sectional study suggest that bisexual female individuals had worse cumulative CVH scores than heterosexual female individuals, whereas gay male individuals generally had better CVH than heterosexual male individuals. There is a need for tailored interventions to improve the CVH of sexual minority adults, particularly bisexual female individuals. Future longitudinal research is needed to examine factors that might contribute to CVH disparities among bisexual female individuals.
Introduction
Cardiovascular disease (CVD) is the leading cause of mortality with more than 19 million deaths worldwide attributed to CVD in 2020.1 In a prospective study of over 155 000 adults in 21 countries, investigators found that modifiable risk factors (such as physical inactivity, unhealthy diet, and hypertension) contributed to approximately 70% of incident CVD and mortality.2 In 2010, the American Heart Association (AHA) developed a measure of ideal cardiovascular health (CVH) that included 3 health behaviors and 4 health factors.3 Multiple studies have found that adults with a lower ideal CVH score have a higher incidence of CVD4,5 and higher all-cause mortality.6,7,8 In 2022, the AHA introduced a revised ideal CVH measure, called Life’s Essential 8, that added sleep as an eighth CVH metric and updated the scoring of CVH metrics.9
Over the past 2 decades, there has been growing evidence that sexual minority (SM; such as lesbian, gay, and bisexual) adults in the US are at greater risk of CVD than their heterosexual counterparts.10 It is hypothesized that CVH disparities in SM adults are due to their exposure to minority stressors, unique stressors that individuals experience due to their minoritized identity (such as discrimination).11 There is consistent evidence that SM men and women have a higher prevalence of current and lifetime tobacco use compared with their heterosexual counterparts.11,12,13 SM women are at higher risk of obesity,11,14,15 diabetes,16,17 and short sleep duration.18 Bisexual men are more likely to meet criteria for obesity, hypertension, and diabetes.19,20 Fewer studies have examined sexual identity differences in physical activity and diet, but findings for SM women and bisexual men are largely mixed.11,21 In contrast, gay men report higher levels of physical activity and better diet quality than heterosexual men.21,22 Similarly, several studies have shown that gay men have lower risk of obesity, hypertension, and diabetes.14,20,23,24
Although individuals with other SM identities (such as pansexual, questioning, or asexual) have worse mental health and substance use outcomes than heterosexual adults,25,26 they have largely been excluded from CVH research.11 A notable exception is an analysis of population-based data that found other SM individuals had a higher prevalence of obesity and lower physical activity than heterosexual adults.27
Overall, research on the CVH of SM adults has focused on examining differences in individual CVH metrics rather than comprehensive measures of CVH.11 Only 1 prior study has examined differences in the AHA’s ideal CVH score between SM and heterosexual adults.28 Using data from a convenience sample of 867 women living in Pittsburgh, Pennsylvania, investigators found that SM women had lower CVH scores than heterosexual women.28 This difference was not explained by traditional risk factors for CVD (such as age and education) or adverse life experiences (such as minority stressors).28
The purpose of this cross-sectional study was to examine sexual identity differences in CVH scores among adults in the US using data from the National Health and Nutrition Examination Survey (NHANES). We also examined sexual identity differences in disease awareness, CVD risk factors, and medication use. Given existing evidence,11 we hypothesized that gay male individuals would have better CVH profiles and that all other groups of SM adults would have worse CVH profiles than their heterosexual counterparts of the same sex.
Methods
Sample
This was a cross-sectional study conducted from June 30 to December 14, 2022, using publicly available NHANES data.29 As a result, this study was deemed exempt by the institutional review board of the Columbia University Irving Medical Center. NHANES data collection was approved by the National Center for Health Statistics ethics review board. Written informed consent was obtained from participants prior to data collection. We used self-reported questionnaires, dietary recall, and physical examination data from NHANES (2007-2016) to examine sexual identity differences in CVH among nonpregnant adult participants with no history of atherosclerotic CVD (including heart attack, stroke, and coronary heart disease) or heart failure and who had complete data for sexual identity and CVH metrics. We did not include NHANES survey years after 2016 as sexual identity data are not publicly available for subsequent years.
The NHANES is a continuous cross-sectional survey focused on estimating the prevalence of major diseases and risk factors for disease in the US. NHANES uses complex multistage probability sampling to achieve a nationally representative sample. Each year, a representative sample of approximately 5000 noninstitutionalized individuals are surveyed across the US; data are released in 2-year cycles. Participants first complete a home questionnaire administered by a trained interviewer using computer-assisted personal interviewing. Approximately 2 weeks later, they attend a mobile examination center (MEC) to complete standardized physiological assessments conducted by trained medical professionals and a 24-hour diet recall.30,31 This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional studies.
Sexual Identity
From 2007 to 2014, participants were asked: “Do you think of yourself as…?” Response options combined sexual identity and attraction (eTable 1 in Supplement 1). After extensive cognitive and field testing,32 the sexual identity item was updated in NHANES 2015 to 2016 to align with measures of the National Health Interview Study. The new item asked: “Which of the following best represents how you think of yourself?” Response options only assessed sexual identity (eTable 1 in Supplement 1). Separate response options were provided for female and male participants. After we excluded participants who responded “refused,” “don’t know,” or “I don’t know the answer” to the sexual identity item, we categorized remaining participants as gay/lesbian, heterosexual, bisexual, or something else based on their responses. The something else category included participants who identified as something other than gay/lesbian, heterosexual, or bisexual. However, we are unable to determine which identities are represented in this category.
Demographic Characteristics
Age was assessed in years. Race and ethnicity were categorized as non-Hispanic Black (hereafter referred to as Black), Hispanic (including Mexican American and other Hispanic), non-Hispanic White (hereafter referred to as White), and non-Hispanic other race (ie, non-Hispanic Asian and multiracial; hereafter referred to as other). Education was categorized as less than high school (including those with less than a ninth-grade education or a 9th- to 11th-grade education), high school graduate or General Education Diploma equivalent, some college, and college graduate or above. The family income to poverty ratio (range, 0-5), provided by NHANES, was calculated by dividing a participant’s total household income by the poverty threshold for that specific survey year. A higher family income to poverty ratio indicates that a participant has a higher household income. Health insurance coverage and whether participants had a routine place for health care were also assessed (yes vs no).
Depressive Symptoms
Prior work has shown that depressive symptoms are inversely associated with CVH scores.33,34 Depressive symptoms in the past 2 weeks were assessed using the 9-item Patient Health Questionnaire.35 Responses summed with higher scores indicated a higher frequency of depressive symptoms (range, 0-27). Cronbach α in the study sample was 0.85.
Disease Awareness
Participants were asked if they had ever been told by a health care professional that they had hypertension, diabetes, or high blood cholesterol. A total of 3 dichotomous variables were created that represented awareness of diagnosis of each of these conditions.
Medication Use
In NHANES, participants who endorsed using prescription medications in the past 30 days completed a medication inventory that included showing interviewers the containers for all medications. If unable to present containers, participants reported the names of their medications. Using these data, 3 dichotomous variables were created that represented use of antihypertensive, glucose-lowering, and lipid-lowering (such as statins) medications.
Ideal CVH
Following recommendations from the AHA’s Life’s Essential 8,9 participants received a score of 0 to 100 for each CVH metric as described in eTable 2 in Supplement 1. Self-report of current and lifetime combustible tobacco use and secondhand smoke exposure (defined as living with someone who smoked in the home) were assessed to determine nicotine exposure (range, 0-100). In addition, participants were asked about the frequency and duration in which they engaged in moderate and vigorous physical activities in a typical week. The number of minutes of moderate and vigorous physical activity per week reported were used to determine physical activity scores.9 We used data from the 24-hour dietary recall interview completed during the MEC visit to assess diet.30 The Healthy Eating Index (2015) was used to assess diet by combining NHANES dietary recall interview data for 13 dietary components with data from the Food Pattern Equivalent Database for 2007 to 2016.36 Higher scores indicate better diet quality (range, 0-100).37 Sleep duration was assessed by asking participants “How much sleep do you usually get at night on weekdays or workdays?” Responses were recoded as described in eTable 2 in Supplement 1.
Biological measures were assessed using standardized assessments completed during the MEC visit, which have been previously described elsewhere.31 We calculated the average systolic and diastolic blood pressure (BP) from 3 consecutive BP readings to determine BP scores. Glycosylated hemoglobin (HbA1c) and lipid levels were obtained by analyzing whole blood specimens. In addition to calculating Life’s Essential 8 for each of these health factors, we created dichotomous variables characterizing elevations in body mass index (BMI),38 BP,39 HbA1c level,40 and non–high-density lipoprotein (HDL) cholesterol level1 based on clinical recommendations. Biological measures were recoded as described in eTable 2 in Supplement 1.
Scores for CVH metrics were summed and divided by 8 to create an unweighted average CVH score with higher scores indicating more favorable CVH. Cumulative scores were then categorized as low (0-49), moderate (50-79), or high (80-100).9
Statistical Analysis
Data were analyzed following analytic guidelines and using recommended survey weights for NHANES data.41 All analyses were sex stratified, and heterosexual participants were the reference group. Approximately 5% of participants had missing values for demographic characteristics and depressive symptoms. Missing data were handled using multiple imputation with chained equations, which has been demonstrated to be useful for handling missingness.42 A total of 20 imputations were run. Each group of SM participants was compared separately with heterosexual participants across study variables using t tests and Rao-Scott design-adjusted χ2 tests. For bivariate analyses, a Bonferroni correction was used to account for multiple comparisons; statistical significance was set at a 2-sided P value <.001.
Sex-stratified logistic regression models were performed to examine sexual identity differences in disease awareness, CVD risk factors, and medication use. Next, sex-stratified linear regression models were used to examine sexual identity differences in Life’s Essential 8 CVH metrics and cumulative ideal CVH scores. Sex-stratified multinomial logistic regression models were used to examine sexual identity differences in the odds of meeting criteria for moderate and high cumulative ideal CVH. For all regression analyses, model 1 was unadjusted and model 2 was adjusted for demographic characteristics, depressive symptoms, and survey year. All analyses were conducted in Stata, version 16 (StataCorp).
Results
The analytic sample included 12 180 participants (mean [SD] age, 39.6 [11.7] years; 6147 male individuals [50.5%]; 6033 female individuals [49.5%]). Participants identified with the following race and ethnicity groups: 2464 Black (11.1%), 3288 Hispanic (15.7%), 5122 White (66.0%), and 1306 other race (7.2%). eFigure in Supplement 1 shows the inclusion and exclusion criteria implemented to obtain the analytic sample for this study. Table 1 presents sexual identity differences across study variables among female individuals. Compared with heterosexual female individuals, bisexual female individuals were younger (mean [SD] age, 31.0 [9.6] years vs 40.5 [11.6] years), more likely to meet criteria for any depression (weighted percentage, 47.60% vs 26.70%), less likely to have been diagnosed with hypertension (weighted percentage, 6.60% vs 16.10%), and less likely to use antihypertensive medications (weighted percentage, 4.80% vs 14.30%). Compared with heterosexual female individuals, bisexual female individuals (mean [SD], 2.3 [1.6] vs 3.0 [1.7]) and female participants who identified their sexual identity as something else (mean [SD], 2.0 [1.5] vs 3.0 [1.7]) had lower family income to poverty ratios.
Table 1. Sexual Identity Differences in Demographic Characteristics, Disease Awareness, Cardiovascular Disease (CVD) Risk Factors, and Medication Use Among Female Participants in the National Health and Nutrition Examination Survey, 2007-2016 (n = 6033)a.
| Demographic characteristics | Heterosexual, weighted % | Lesbian | Bisexual | Something elseb | |||
|---|---|---|---|---|---|---|---|
| Weighted % | P value | Weighted % | P value | Weighted % | P value | ||
| No. | 5629 | 82 | NA | 270 | NA | 52 | NA |
| Age (range 18-59), mean (SD), y | 40.5 (11.60) | 37.7 (10.90) | .12 | 31.0 (9.58) | <.001 | 38.8 (13.13) | .37 |
| Race and ethnicityc | |||||||
| Non-Hispanic Black | 11.70 | 15.10 | .66 | 11.70 | .19 | 14.40 | .002 |
| Hispanic | 15.40 | 11.50 | 11.00 | 28.40 | |||
| Non-Hispanic White | 66.20 | 65.30 | 68.10 | 36.60 | |||
| Non-Hispanic other raced | 6.70 | 8.10 | 9.20 | 20.60 | |||
| Family income to poverty ratio (range 0-5), mean (SD) | 3.0 (1.7) | 2.5 (1.6) | .02 | 2.3 (1.6) | <.001 | 2.0 (1.5) | <.001 |
| Education | |||||||
| Less than high school | 12.60 | 15.80 | .91 | 14.40 | .003 | 30.00 | .02 |
| High school/GED equivalent | 19.50 | 17.50 | 23.40 | 16.50 | |||
| Some college | 34.30 | 35.00 | 43.00 | 35.20 | |||
| College graduate or above | 33.60 | 31.70 | 19.20 | 18.30 | |||
| Health insurance coverage | 81.60 | 70.60 | .04 | 71.20 | .002 | 66.80 | .05 |
| Routine place for health care | 87.60 | 77.10 | .05 | 79.90 | .007 | 77.40 | .20 |
| Depression | |||||||
| None | 73.30 | 68.30 | .41 | 52.40 | <.001 | 71.00 | .96 |
| Mild | 16.90 | 17.50 | 24.50 | 20.00 | |||
| Moderate | 6.10 | 7.90 | 14.30 | 5.30 | |||
| Moderately severe | 2.80 | 3.10 | 5.90 | 2.40 | |||
| Severe | 0.90 | 3.20 | 2.90 | 1.30 | |||
| Disease awareness: diagnosis | |||||||
| Hypertension | 16.10 | 15.40 | .91 | 6.60 | <.001 | 14.80 | .78 |
| Diabetes | 5.20 | 5.40 | .99 | 2.80 | .09 | 4.10 | .66 |
| High blood cholesterol | 25.20 | 26.20 | .9 | 14.50 | .001 | 18.90 | .33 |
| CVD risk factors | |||||||
| Current smoking | 20.70 | 43.20 | <.001 | 42.70 | <.001 | 17.20 | .62 |
| Meets physical activity recommendationse | 58.20 | 67.20 | .24 | 64.00 | .13 | 60.50 | .80 |
| Diet quality, mean (SD) | 52.1 (14.2) | 49.6 (13.4) | .27 | 49.4 (13.9) | .06 | 50.6 (17.3) | .58 |
| Sleep duration, mean (SD), h | 7.0 (1.4) | 7.0 (1.5) | .99 | 7.3 (1.7) | .11 | 7.4 (2.0) | .28 |
| BMI, mean (SD)f | 28.6 (7.4) | 30.4 (7.0) | .13 | 29.7 (7.8) | .07 | 29.3 (7.6) | .48 |
| Obesity (≥30) | 35.00 | 43.80 | .25 | 43.90 | .01 | 43.70 | .29 |
| Blood pressure, mean (SD), mm Hg | |||||||
| Systolic | 115.5 (14.3) | 117.3 (15.4) | .48 | 113.5 (10.9) | .03 | 116.1 (18.6) | .79 |
| Diastolic | 70.0 (10.5) | 70.4 (11.5) | .83 | 68.3 (10.5) | .04 | 67.6 (13.2) | .17 |
| Elevated (SBP >130/DBP >80) | 22.30 | 22.30 | .99 | 17.30 | .13 | 19.50 | .63 |
| Glycosylated hemoglobin, mean (SD), % | 5.5 (0.) | 5.5 (0.6) | .71 | 5.3 (0.7) | <.01 | 5.5 (0.9) | .44 |
| Elevated HbA1c (≥6.5%) | 4.20 | 1.00 | .13 | 1.60 | <.01 | 5.00 | .78 |
| Non-HDL, mean (SD), mg/dL | 137.7 (40.5) | 135.9 (41.0) | .73 | 130.6 (40.0) | .02 | 135.9 (38.4) | .72 |
| Elevated non-HDL cholesterol, ≥130 mg/dL | 53.60 | 57.60 | .56 | 47.60 | .10 | 69.40 | .09 |
| Medication use | |||||||
| Use of antihypertensive medication | 14.30 | 13.80 | .94 | 4.80 | <.001 | 12.90 | .81 |
| Use of glucose-lowering medication | 4.20 | 2.90 | .59 | 4.50 | .86 | 6.20 | .45 |
| Use of lipid-lowering medication | 7.70 | 0 | .10 | 1.10 | .001 | 5.50 | .60 |
Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; GED, General Educational Diploma; HbA1c, glycosylated hemoglobin; HDL, high-density lipoprotein; NA, not applicable; SBP, systolic blood pressure.
SI conversion factor: To convert HbA1c to proportion of total hemoglobin, multiply by 0.01; non-HDL cholesterol to millimoles per liter, multiply by 0.0259; and HDL cholesterol to millimoles per liter, multiply by 0.0259.
To examine sexual identity differences across study variables, t tests and Rao-Scott χ2 tests were used. Heterosexual female participants were the reference group for all analyses, and all P values reflect analyses separately comparing female participants identifying as lesbian, bisexual, or something else with heterosexual female participants.
The something else category included participants who identified as something other than gay/lesbian, heterosexual, or bisexual.
Hispanic included Mexican American participants and those who self-identified Hispanic ethnicity. Non-Hispanic other race included non-Hispanic Asian participants and other non-Hispanic participants such as those who were multiracial.
Other race and ethnicity includes non-Hispanic Asian and multiracial.
Meeting physical activity recommendations was defined as 150 or more minutes of moderate and/or vigorous aerobic physical activity per week based on Life’s Essential 8 recommendations.
Calculated as weight in kilograms divided by height in meters squared.
Table 2 presents sexual identity differences across study variables among male individuals. Compared with heterosexual male individuals, bisexual male individuals (weighted percentage, 40.20% vs 19.00%) and male participants who identified their sexual identity as something else (weighted percentage, 36.50% vs 19.00%) were more likely to meet criteria for any depression. Bisexual male individuals also had lower family income to poverty ratios than heterosexual male individuals (mean [SD], 2.3 [1.9] vs 3.1 [1.7]). No differences were found between gay and heterosexual male individuals.
Table 2. Sexual Identity Differences in Demographic Characteristics, Disease Awareness, Cardiovascular Disease (CVD) Risk Factors, and Medication Use Among Male Participants in the National Health and Nutrition Examination Survey, 2007-2016 (n = 6147)a.
| Demographic characteristics | Heterosexual, Weighted % | Gay | Bisexual | Something elseb | |||
|---|---|---|---|---|---|---|---|
| Weighted % | P value | Weighted % | P value | Weighted % | P value | ||
| No. | 5888 | 130 | 99 | 30 | |||
| Age (range 18-59), mean (SD), y | 39.2 (11.67) | 40.6 (11.12) | .41 | 36.0 (13.56) | .03 | 35.1 (10.09) | .09 |
| Race and ethnicityc | |||||||
| Non-Hispanic Black | 10.40 | 10.30 | .61 | 12.80 | .35 | 9.10 | .39 |
| Hispanic | 16.20 | 14.10 | 18.20 | 18.70 | |||
| Non-Hispanic White | 65.80 | 70.60 | 61.70 | 59.00 | |||
| Non-Hispanic other raced | 7.60 | 5.00 | 7.30 | 13.20 | |||
| Family income to poverty ratio (range 0-5), mean (SD) | 3.1 (1.7) | 3.0 (1.5) | .57 | 2.3 (1.9) | <.001 | 2.9 (1.4) | .52 |
| Education | |||||||
| Less than high school | 14.70 | 3.00 | .006 | 11.70 | .38 | 18.90 | .37 |
| High school/GED equivalent | 23.60 | 15.50 | 27.80 | 6.40 | |||
| Some college | 31.90 | 40.10 | 39.20 | 34.10 | |||
| College graduate or above | 29.80 | 41.40 | 21.30 | 40.60 | |||
| Health insurance coverage | 75.20 | 84.80 | .05 | 73.60 | .74 | 66.80 | .05 |
| Routine place for health care | 75.50 | 83.00 | .08 | 74.00 | .81 | 64.30 | .32 |
| Depression | |||||||
| None | 81.00 | 70.10 | .03 | 59.80 | <.001 | 63.50 | <.001 |
| Mild | 13.10 | 19.30 | 28.20 | 15.40 | |||
| Moderate | 3.70 | 9.40 | 6.20 | 10.60 | |||
| Moderately severe | 1.50 | 0 | 5.80 | 0.00 | |||
| Severe | 0.70 | 1.20 | 0.00 | 10.50 | |||
| Disease awareness: diagnosis | |||||||
| Hypertension | 15.40 | 12.40 | .39 | 22.20 | .14 | 11.10 | .55 |
| Diabetes | 5.00 | 5.90 | .71 | 8.60 | .19 | 2.60 | .51 |
| High blood cholesterol | 27.10 | 28.20 | .80 | 19.00 | .15 | 8.40 | .05 |
| CVD risk factors | |||||||
| Current smoking | 24.90 | 28.70 | .53 | 34.00 | .05 | 30.90 | .55 |
| Meets physical activity recommendationse | 72.20 | 65.50 | .27 | 73.00 | .90 | 54.10 | .11 |
| Diet quality, mean (SD) | 49.6 (13.5) | 54.2 (12.6) | .01 | 50.8 (15.08) | .44 | 47.3 (15.7) | .63 |
| Sleep duration, mean (SD), h | 6.9 (1.3) | 7.3 (1.1) | <.01 | 7.2 (1.7) | .15 | 7.9 (1.5) | <.01 |
| BMI, mean (SD)f | 28.7 (6.0) | 26.9 (5.2) | .02 | 27.9 (8.2) | .46 | 27.2 (6.4) | .29 |
| Obesity ≥30 | 34.40 | 24.10 | .1 | 38.20 | .58 | 22.20 | .23 |
| Blood pressure, mean (SD), mm Hg | |||||||
| Systolic | 121.1 (13.2) | 118.6 (11.1) | .09 | 119.7 (12.8) | .27 | 123.6 (11.5) | .26 |
| Diastolic | 72.8 (11.4) | 72.5 (9.4) | .81 | 70.8 (13.7) | .17 | 72.5 (9.0) | .87 |
| Elevated (SBP ≥130/DBP ≥80) | 33.30 | 28.60 | .41 | 24.80 | .12 | 40.30 | .54 |
| HbA1c level, mean (SD), % | 5.5 (0.9) | 5.3 (0.4) | <.01 | 5.6 (1.4) | .54 | 5.4 (0.6) | .28 |
| Elevated HbA1c, ≥6.5% | 5.20 | 2.20 | .15 | 9.00 | .16 | 2.50 | .45 |
| Non-HDL, mean (SD), mg/dL | 147.7 (42.6) | 145.2 (38.0) | .59 | 136.7 (72.2) | .20 | 132.2 (37.9) | .09 |
| Elevated non-HDL cholesterol, ≥130 mg/dL | 64.60 | 60.30 | .45 | 50.70 | .02 | 56.60 | .57 |
| Medication use | |||||||
| Use of antihypertensive medication | 12.20 | 9.40 | .48 | 18.50 | .14 | 11.30 | .91 |
| Use of glucose-lowering medications | 4.30 | 6.20 | .47 | 8.60 | .09 | 2.50 | .59 |
| Use of lipid-lowering medications | 9.60 | 8.50 | .75 | 9.60 | .99 | 0.00 | .23 |
Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; GED, General Educational Diploma; HbA1c, glycosylated hemoglobin; HDL, high-density lipoprotein; NA, not applicable; SBP, systolic blood pressure.
SI conversion factor: To convert HbA1c to proportion of total hemoglobin, multiply by 0.01; non-HDL cholesterol to millimoles per liter, multiply by 0.0259; and HDL cholesterol to millimoles per liter, multiply by 0.0259.
To examine sexual identity differences across study variables, t tests and Rao-Scott χ2 tests were used. Heterosexual male participants were the reference group for all analyses, and all P values reflect analyses separately comparing male participants identifying as gay, bisexual, or something else with heterosexual male participants.
The something else category included participants who identified as something other than gay/lesbian, heterosexual, or bisexual.
Hispanic included Mexican American participants and those who self-identified Hispanic ethnicity. Non-Hispanic other race included non-Hispanic Asian participants and other non-Hispanic participants such as those who were multiracial.
Other race and ethnicity includes non-Hispanic Asian and multiracial.
Meeting physical activity recommendations was defined as 150 or more minutes of moderate and/or vigorous aerobic physical activity per week based on Life’s Essential 8 recommendations.
Calculated as weight in kilograms divided by height in meters squared.
As shown in Figure 1, compared with heterosexual female individuals, lesbian (mean [SD] score, 52.1 [45.7] vs 72.9 [39.9]; P <.001) and bisexual (mean [SD] score, 51.2 [45.8] vs 72.9 [39.9]) female individuals had less favorable scores for nicotine exposure. No significant differences in CVH were found when comparing lesbian female individuals and female participants who identified their sexual identity as something else with heterosexual female individuals. As shown in Figure 2, compared with heterosexual male individuals, gay male individuals had generally more favorable scores for diet (mean [SD], 50.8 [27.6] vs 38.3 [30.9]; P = .004), BP (mean [SD], 79.2 [21.6] vs 75.4 [25.3]; P = .20), and glycemic status (mean [SD], 93.4 [15.6] vs 88.4 [22.4]; P = .03) than heterosexual male individuals; however, these differences were not statistically significant. No significant differences in CVH were found when comparing bisexual male individuals and male participants who identified their sexual identity as something else relative to heterosexual male individuals.
Figure 1. Sexual Identity Differences in Ideal Cardiovascular Health (CVH) Metrics and Cumulative Ideal CVH Among Female Participants.
A, Meeting physical activity recommendations was defined as greater than or equal to 150 minutes of moderate and/or vigorous aerobic physical activity per week based on Life's Essential 8 recommendations. B, Glycemic status was assessed using glycosylated hemoglobin. C, Blood lipids were assessed by calculating non–high-density lipoprotein (HDL) cholesterol (defined as the difference between total cholesterol and HDL cholesterol). D, Cumulative ideal CVH score is the unweighted average of the 8 CVH metrics, range 0 to 100. The something else category included female participants who identified as something other than gay/lesbian, heterosexual, or bisexual.
Figure 2. Sexual Identity Differences in Ideal CVH Metrics and Cumulative Ideal CVH Among Male Participants.
A, Meeting physical activity recommendations was defined as greater than or equal to 150 minutes of moderate and/or vigorous aerobic physical activity per week based on Life's Essential 8 recommendations. B, Glycemic status was assessed using glycosylated hemoglobin. C, Blood lipids were assessed by calculating non–high density lipoprotein (HDL) cholesterol (defined as the difference between total cholesterol and HDL cholesterol). D, Cumulative ideal CVH score is the unweighted average of the 8 CVH metrics, range 0 to 100. The something else category included male participants who identified as something other than gay/lesbian, heterosexual, or bisexual.
eTable 3 in Supplement 1 presents results of logistic regression models examining sexual identity differences in disease awareness, CVD risk factors, and medication use. Bisexual female individuals were more likely to meet criteria for obesity (adjusted odds ratio [aOR], 1.52; 95% CI, 1.10-2.10) than heterosexual female individuals. Bisexual male individuals were more likely than heterosexual male individuals to report a diagnosis of hypertension (aOR, 1.98; 95% CI, 1.10-3.56) and to use antihypertensive medication (aOR, 2.20; 95% CI, 1.12-4.32).
Table 3 presents results of linear regression models examining sexual identity differences in CVH. In fully adjusted models, lesbian (B = −17.21; 95% CI, −31.98 to −2.44) and bisexual (B = −13.76; 95% CI, −20.54 to −6.99) female individuals had less favorable nicotine exposure scores compared with heterosexual female individuals. Bisexual female individuals had less favorable BMI scores (B = −7.47; 95% CI, −12.95 to −1.97) and lower cumulative CVH scores than heterosexual female individuals (B = −2.59; 95% CI, −4.84 to −0.33). Among male individuals, gay male participants had less favorable nicotine exposure scores (B = −11.43; 95% CI, −21.87 to −0.99). In contrast, gay male individuals had more favorable diet (B = 9.65; 95% CI, 2.38-16.92), BMI (B = 9.75; 95% CI, 1.25-18.25) and glycemic status (B = 5.28; 95% CI, 0.59-9.97) scores relative to heterosexual male individuals. Bisexual male participants had more favorable blood lipid scores than heterosexual male participants (B = 6.80; 95% CI, 0.56-13.05). No differences in CVH were found when comparing female and male participants who identified their sexual identity as something else with heterosexual participants of the same sex.
Table 3. Results of Linear Regression Models Examining Sexual Identity Differences in Individual Cardiovascular Health (CVH) Metrics and Cumulative CVH Scores (N = 12 180).
| CVH metrics | B (95% CI) | |||
|---|---|---|---|---|
| Female individuals (n = 6033) | Male individuals (n = 6147) | |||
| Model 1a | Model 2b | Model 1a | Model 2b | |
| Nicotine exposure | ||||
| Heterosexual | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Gay/lesbian | −20.84 (−34.74 to −6.94)c | −17.21 (−31.98 to −2.44)d | −8.97 (−21.48 to 3.54) | −11.43 (−21.87 to −0.99)d |
| Bisexual | −21.72 (−29.49 to −13.94)e | −13.76 (−20.54 to −6.99)e | −9.68 (−20.71 to 1.34) | −5.41 (−16.09 to 5.27) |
| Something elsef | 8.06 (−5.36 to 21.47) | 9.56 (−1.35 to 20.46) | −3.66 (−23.83 to 16.51) | −4.68 (−18.75 to 9.38) |
| Physical activity | ||||
| Heterosexual | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Gay/lesbian | 6.74 (−5.88 to 19.37) | 7.83 (−5.57 to 21.22) | −4.26 (−13.47 to 4.95) | −4.54 (−14.01 to 4.92) |
| Bisexual | 4.25 (−2.19 to 10.68) | 4.38 (−1.45 to 10.20) | −1.82 (−11.91 to 8.27) | −0.92 (−10.42 to 8.58) |
| Something elsef | −6.54 (−24.81 to 11.74) | −0.21 (−15.37 to 14.96) | −14.26 (−33.71 to 5.19) | −15.22 (−33.98 to 3.54) |
| Diet | ||||
| Heterosexual | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Gay/lesbian | −7.31 (−17.34 to 2.72) | −4.70 (−16.22 to 6.83) | 12.58 (4.03 to 21.12)c | 9.65 (2.38 to 16.92)d |
| Bisexual | −4.69 (−10.46 to 1.09) | 2.69 (−3.06 to 8.43) | 0.81 (−6.61 to 8.24) | 3.04 (−4.00 to 10.26) |
| Something elsef | −4.21 (−15.64 to 7.22) | −2.07 (−12.50 to 8.36) | −5.36 (−25.62 to 14.90) | −7.42 (−28.01 to 12.45) |
| Sleep | ||||
| Heterosexual | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Gay/lesbian | −1.41 (−10.63 to 7.80) | 0.24 (−9.24 to 9.73) | 4.53 (−0.74 to 9.81) | 4.80 (−0.05 to 9.66) |
| Bisexual | −5.86 (−10.54 to −1.20)d | −2.20 (−6.98 to 2.59) | −1.77 (−8.52 to 4.99) | 0.97 (−5.93 to 7.86) |
| Something elsef | −2.86 (−13.69 to 7.96) | −1.02 (−11.09 to 9.05) | 1.61 (−10.16 to 13.38) | 1.40 (−6.87 to 9.67) |
| BMI | ||||
| Heterosexual | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Gay/lesbian | −8.69 (−20.35 to 2.97) | −8.20 (−19.82 to 3.42) | 8.79 (0.77 to 16.81)d | 9.75 (1.25 to 18.25)d |
| Bisexual | −6.96 (−12.38 to −1.54)d | −7.47 (−12.95 to −1.97)c | 2.34 (−7.94 to 12.62) | 2.15 (−7.79 to 12.10) |
| Something elsef | −5.67 (−16.28 to 4.94) | −3.25 (−13.61 to 7.12) | 14.07 (−0.70 to 28.86) | 10.01 (−2.08 to 22.09) |
| Blood pressure | ||||
| Heterosexual | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Gay/lesbian | −1.71 (−8.06 to 4.63) | −3.06 (−8.47 to 2.34) | 3.86 (−2.02 to 9.74) | 4.34 (−1.83 to 10.50) |
| Bisexual | 4.93 (1.96 to 7.90)c | −1.25 (−3.98 to 1.49) | 2.68 (−3.45 to 8.81) | 1.63 (−3.84 to 7.12) |
| Something elsef | 2.37 (−4.25 to 8.98) | 2.77 (−4.72 to 10.26) | −0.83 (−12.94 to 11.29) | −3.84 (−13.83 to 6.14) |
| Glycemic status g | ||||
| Heterosexual | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Gay/lesbian | −2.24 (−10.32 to 5.84) | −2.91 (−10.09 to 4.27) | 4.99 (0.52 to 9.64)d | 5.28 (0.59 to 9.97)d |
| Bisexual | 3.40 (0.89 to 5.91)c | −0.91 (−3.33 to 1.52) | −2.30 (−9.06 to 4.46) | −2.82 (−9.20 to 3.55) |
| Something elsef | −2.96 (−9.95 to 4.03) | −0.56 (−7.25 to 6.13) | 0.92 (−7.27 to 9.12) | 1.47 (−7.98 to 5.04) |
| Blood lipids h | ||||
| Heterosexual | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Gay/lesbian | 0.05 (−7.08 to 7.18) | −2.18 (−8.07 to 3.71) | 1.78 (−5.65 to 9.22) | 1.28 (−4.57 to 7.13) |
| Bisexual | 4.60 (0.25 to 8.94)d | −2.17 (−6.44 to 2.09) | 8.60 (1.63 to 15.57)d | 6.80 (0.56 to 13.05)d |
| Something elsef | −2.69 (−11.02 to 5.63) | −3.36 (−11.88 to 5.16) | 10.26 (−3.88 to 24.40) | 3.59 (−9.51 to 16.69) |
| Cumulative ideal CVH i | ||||
| Heterosexual | 1 [Reference] | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Gay/lesbian | −4.43 (−11.18 to 2.33) | −3.78 (−10.64 to 3.09) | 2.94 (−1.26 to 7.09) | 2.39 (−1.52 to 6.30) |
| Bisexual | −2.76 (−5.28 to −0.24)d | −2.59 (−4.84 to −0.33)d | −0.14 (−4.13 to 3.85) | 0.69 (−2.70 to 4.09) |
| Something elsef | −1.81 (−7.75 to 4.13) | 0.23 (−4.80 to 5.26) | 0.35 (−6.62 to 7.32) | −2.24 (−6.37 to 1.87) |
Abbreviation: BMI, body mass index.
Model 1 was unadjusted.
Model 2 was adjusted for age, race and ethnicity, family income ratio to poverty ratio, education, health insurance coverage, routine place for health care, depression, and survey year.
P < .01.
P < .05.
P < .001.
The something else category included participants who identified as something other than gay/lesbian, heterosexual, or bisexual.
Glycemic status was assessed using glycosylated hemoglobin.
Blood lipids was assessed by calculating non–high-density lipoprotein cholesterol.
Cumulative CVH score is the unweighted average of the 8 CVH metrics.
Results of multinomial logistic regression models examining sexual identity differences in poor, moderate, and high CVH found that bisexual female individuals were approximately half as likely as heterosexual female individuals to meet criteria for high CVH (aOR, 0.52; 95% CI, 0.28-0.96) relative to low CVH. No differences in ideal CVH were found between other groups of SM participants and their heterosexual counterparts (eTable 4 in Supplement 1).
Discussion
As the first, to our knowledge, nationally representative study to examine sexual identity differences in ideal CVH among adults in the US, our findings represent an important contribution to existing research on CVH disparities among SM adults.11 Consistent with our hypotheses, bisexual female individuals had less favorable CVH profiles than heterosexual female individuals. However, we found no differences in cumulative ideal CVH between other groups of SM adults and their heterosexual counterparts.
Consistent with these findings, researchers have documented that bisexual women have a higher prevalence of nicotine exposure and excess weight compared with heterosexual women.11,12,13,28 Bisexual female individuals in the present study were also less likely to have high ideal CVH scores, which may place them at greater risk of incident CVD and mortality.7,8 Prior research has shown that SM women in the US are at higher risk of cancer and all-cause mortality compared with heterosexual women,43,44 but no differences in CVD mortality have been documented.44
There are several reasons why bisexual female individuals may have worse CVH than heterosexual female individuals. First, bisexual individuals have worse mental health and substance use outcomes relative to monosexual (including gay/lesbian and heterosexual) individuals,12,45 which are attributed to greater minority stress due to exposure to discrimination and/or rejection from both their gay/lesbian and heterosexual peers.12,46 However, this does not explain why results of the current study found that bisexual female individuals, but not bisexual male individuals, had worse CVH. Further, bisexual women in the US report the highest likelihood of living in poverty relative to all sexual identity groups, even compared with bisexual men.47 Bisexual women are also more likely to delay health care due to financial concerns and to report having difficulty finding a health care professional than heterosexual women,14,48 which may make them less likely to obtain preventive screening for CVD and other chronic conditions. Although it is likely that minority stress and socioeconomic disadvantage contribute to higher risk of poor CVH among bisexual women, this has not been comprehensively tested in prior research.11
Consistent with prior work, we found that with the exception of a higher prevalence of tobacco use,11,12 gay male individuals have more favorable scores for diet, BMI, and glycemic status scores than heterosexual male individuals.15,19,20,24 Our findings are consistent with the few studies that have used the Healthy Eating Index to examine diet quality among gay men.21 These results are also consistent with research indicating that gay men are less likely to be obese than heterosexual men.11,13,15 Previous evidence on differences in glycemic status between gay and heterosexual men is conflicting.11,13 Reasons for the generally more favorable CVH profile observed among gay male individuals in the present study are unclear. However, researchers have found that a desire to conform to body ideals of thinness within the gay community may contribute to excessive exercising and dieting resulting in lower excess weight among gay men.22,49 Another explanation is that gay men are more likely to obtain preventive health care services compared with heterosexual and other groups of SM men, which may contribute to greater engagement in behaviors that are associated with better CVH.50,51
To our knowledge, this was the first study to identify that bisexual male individuals have more favorable lipid profiles compared with heterosexual male individuals. In contrast, bisexual male individuals were twice as likely as heterosexual male individuals to have been diagnosed with hypertension and to use antihypertensive medication. This is consistent with evidence from prior work.19,20 Findings from our study highlight the need to formally investigate reasons why bisexual male individuals may simultaneously have more favorable lipid profiles but higher risk of hypertension than heterosexual male individuals.
Our findings are consistent with the only prior study that examined sexual identity differences in ideal CVH among adults.28 In a community sample of 867 women, investigators found that SM (combined gay/lesbian and bisexual) women had lower CVH scores than heterosexual women, which were primarily attributed to a higher prevalence of nicotine exposure and obesity.28 The present study has notable strengths compared to the aforementioned study.28 Our study was nationally representative and included male and female participants. We were also able to separately examine ideal CVH in gay/lesbian and bisexual participants. Although we found no CVH disparities among participants who identified their sexual identity as something else, the present study was the first, to our knowledge, to examine ideal CVH among these individuals who remain understudied within CVH research.
This study has important clinical and research implications. To date, there are no rigorously tested interventions focused on promoting the CVH of SM adults.11 Findings suggest the need to develop, test, and disseminate interventions to improve CVH among SM adults. Whereas smoking cessation should be a priority for SM female individuals and gay male individuals; hypertension risk should be addressed among bisexual male individuals. Health care professionals should be educated about the CVH disparities observed among SM adults to improve their ability to provide culturally tailored care for these patients. Existing research on the CVH of SM adults largely consists of cross-sectional studies, which has prevented examination of long-term CVH outcomes (such as incident CVD and CVD mortality) in this population.11 Further, NHANES does not include data on social determinants that have been found to influence the CVH of SM individuals (such as discrimination and interpersonal violence).52,53 Our findings suggest the need for longitudinal studies that comprehensively examine factors that may contribute to poor CVH among bisexual female individuals. Researchers should also investigate factors that may be associated with better CVH among gay male individuals.
Limitations
This study has several limitations. Given that NHANES is a cross-sectional survey, causality cannot be inferred from our findings. Also, the sample sizes of lesbian female individuals, bisexual male individuals, and participants who identified their sexual identity as something else were small, which may have limited statistical power. Investigators have found that individuals who report their sexual identity as something else represent a heterogeneous group of individuals (such as pansexual, questioning, or asexual people) who do not feel represented by common response options to sexual identity items in health surveys.26,54 Although we found no differences in CVH between participants who reported identifying as something else vs those who were heterosexual, future work is needed to better understand the CVH of this group. Residual confounding may have biased model estimates. Given that we were unable to account for the influence of minority stressors on CVH, our analyses were limited to examining differences in CVH by sexual identity. Gender identity is not assessed in NHANES; therefore, we were unable to identify gender minority (such as transgender) participants who have been previously shown to have higher CVD risk than nontransgender adults.55
Another limitation is the changes to sexual identity items and response options used across NHANES 2007 to 2016. One could hypothesize that the responses in NHANES 2007 to 2014 that incorporated both sexual identity and attraction would result in more participants identifying as SM; however, this was not the case. The percentage of SM participants in the current sample increased over time and was highest during the 2015 to 2016 cycle (4.3% in 2007-2008 to 7.4% in 2015-2016) even though response options that period only included sexual identity. We are unable to test if changes to the sexual identity item in NHANES affected our findings. However, in sensitivity analyses restricting our analyses to 2007 to 2014 data, we found no substantive differences in our interpretations.
Conclusions
In conclusion, results of this cross-sectional study suggest that bisexual female individuals and gay/lesbian adults had greater nicotine exposure than heterosexual adults. Bisexual female individuals had worse cumulative CVH scores than heterosexual female individuals, whereas gay male individuals generally had better CVH than heterosexual male individuals. There is a need for tailored interventions to improve the CVH of SM individuals, particularly bisexual female individuals. Investigators should conduct longitudinal research that examines social determinants that may explain the sexual identity differences observed in this study.
eFigure. Flowchart of Inclusion and Exclusion Criteria
eTable 1. Sexual Identity Measures in the NHANES 2007-2016
eTable 2. Scoring of Cardiovascular Health
eTable 3. Results of Logistic Regression Models Examining Sexual Identity Differences in Disease Awareness, CVD Risk Factors, and Medication Use
eTable 4. Results of Multinomial Logistic Regression Models Examining Sexual Identity Differences in Poor, Moderate, and High Cumulative Cardiovascular Health
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure. Flowchart of Inclusion and Exclusion Criteria
eTable 1. Sexual Identity Measures in the NHANES 2007-2016
eTable 2. Scoring of Cardiovascular Health
eTable 3. Results of Logistic Regression Models Examining Sexual Identity Differences in Disease Awareness, CVD Risk Factors, and Medication Use
eTable 4. Results of Multinomial Logistic Regression Models Examining Sexual Identity Differences in Poor, Moderate, and High Cumulative Cardiovascular Health
Data Sharing Statement
