Obesity and Eating Disorder Disparities Among Sexual and Gender Minority Youth

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.

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.

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.

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.

Corresponding Author: Natasha A. Schvey, PhD, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences (USU), 4301 Jones Bridge Rd, Bethesda, MD 20814 (natasha.schvey@usuhs.edu).

Accepted for Publication: May 18, 2020.

Published Online: December 28, 2020. doi:10.1001/jamapediatrics.2020.5152

Author Contributions: Drs Schvey and Gray had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Schvey, Klein.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Schvey, Pearlman, Klein.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Schvey, Gray.

Administrative, technical, or material support: Schvey, Klein, Murphy.

Supervision: Klein.

Conflict of Interest Disclosures: None reported.

Disclaimer: The opinions and assertions expressed herein are those of the authors and are not to be construed as reflecting the views of Uniformed Services University (USU) or the US Department of Defense.

Additional Information: Data used in the preparation of this article were obtained from the Adolescent Brain Cognitive Development (ABCD) Study (https://abcdstudy.org), held in the National Institute of Mental Health Data Archive (NDA). This is a multisite, longitudinal study designed to recruit more than 10 000 children aged 9 to 10 years and follow-up with them over 10 years into early adulthood. The ABCD Study is supported by the National Institutes of Health and additional federal partners under award numbers U01DA041022, U01DA041028, U01DA041048, U01DA041089, U01DA041106, U01DA041117, U01DA041120, U01DA041134, U01DA041148, U01DA041156, U01DA041174, U24DA041123, and U24DA041147. A full list of supporters is available at https://abcdstudy.org/federal-partners/. A listing of participating sites and a complete listing of the study investigators can be found at https://abcdstudy.org/principal-investigators.html. ABCD consortium investigators designed and implemented the study and/or provided data but did not necessarily participate in analysis or writing of this report. This article reflects the views of the authors and may not reflect the opinions or views of the National Institutes of Health or ABCD consortium investigators. The ABCD data repository grows and changes over time.