Design
The purpose of this case series was to depict the food and nutrition considerations of adult transgender men. Ten participants were recruited using direct mail and word-of-mouth. Participants were at least 18 years of age and identified as transgender male or transmasculine, and may or may not have pursued gender-affirming medical interventions such as hormone therapy or surgeries. Transfeminine and non-binary participants were excluded from this study given that the researchers felt the nutrition considerations may be distinct enough to warrant separate studies focused on other gender identities. Participants provided written consent and were remunerated with a nominal gift card. The Saint Louis University Institutional Review Board approved this study.
Data collection and analysis
Data collection occurred from October 2018 to February 2019 and included anthropometric, survey, and dietary recall data. The reference source for each data type is expressed in Table 1. Anthropometric data included BMI, waist circumference, and body fat percentage. Survey data included two nutrition screeners related to disordered eating: the EAT-26 and ecSI-2. The EAT-26 estimates eating disorder risk and has been validated with adolescent and adult populations; a score of 20/26 or higher was the cutoff for high eating disorder risk [10]. The ecSI-2 measures eating competence, which is characterized by a positive, comfortable, and flexible approach to food, and has been validated with various adult populations across income groups; a score of 32/48 or higher was the cutoff for high eating competence [11]. Data collection also included a patient interview; this data will be analyzed separately, but short segments were included in this case series in order to better contextualize the narrative of each case.
A diet analysis of each participant was conducted using a three-day food diary and the software ESHA Food Processor Nutrition Analysis. Energy needs to maintain weight were calculated using the Estimated Energy Requirement (EER) formula, which accounts for height, weight, age, activity level, and gender. The percentage of kcal intake from each macronutrient was compared to the Acceptable Macronutrient Distribution Ranges (AMDR) for carbohydrates, fat and protein.
Recommended Dietary Allowances (RDA) or Adequate Intake (AI) values were used for fiber, calcium, vitamin D, potassium, and iron needs. Percent intake values +/− 0–10% the Dietary Reference Intakes (DRI) were characterized as adequate; +/− 11–20% the DRI were characterized as marginally high or low; +/− > 20% the DRI were characterized as high or low.
The Dietary Guidelines for Americans (DGAs) 2015–2020 were used as the reference recommendations for saturated fat (< 10% total kcals) and sodium (< 2300 mg/day). In the case presentations, saturated fat intake of 0–10% of total kcals was characterized as appropriate; 11–15% was characterized as marginally high; > 15% was characterized as high. For sodium, intake of 0–110% the recommendation was characterized as appropriate; 111–120% was characterized as marginally high; > 120% was characterized as high.
As depicted in Table 1, many of the data types are gender-specific in that they provide specific recommendations for males and females. The research team opted to utilize the male values given that the participants were either receiving hormone therapy or intended to do so in the near future.
Research team
An interdisciplinary clinical research team analyzed the data individually for each case and identified trends across the ten cases. The team was comprised of a registered dietitian with a research focus on nutrition care for the transgender population, a family physician who provides gender-affirming medical care for patients at a community health center, and a reproductive endocrinologist who provides gender-affirming medical care for patients at an area hospital. The research team was selected given their content expertise in medicine and dietetics, as well as their activity in both research and direct patient care with the transgender population.
Case presentations
The following cases are presented in order of age from youngest to oldest. Coded initials are used to ensure confidentiality. The results are depicted in Table 2.
Case 1
BN is a 22 year-old transgender male and was just about to start hormone therapy. He works night shifts and notes, “I just don’t eat what I should.” BN is hopeful that his diet and exercise will improve moving forward and that “testosterone’s going to help weight distribution and things like that.”
BN has a BMI of 45 kg/m2, body fat percentage of 40% and waist circumference of 56 in., indicating class III obesity and central adiposity. He has a low risk of eating disorders (5/26 on the EAT-26) and yet a low degree of eating competence (16/48 on the ecSI-2). His dietary pattern includes 3–4 eating instances per day at home, work, or fast food restaurants. BN consumes 0–1 servings of fruits and vegetables per day and has a high intake of added sugars in the form of sodas, sweetened tea, and ice cream.
BN’s diet analysis was characterized by low energy (59% kcal needs), appropriate saturated fat (10% kcal intake), low fiber (45% AI) and high sodium (149% DGAs limit). His macronutrient intake was 48% carbohydrate, 37% fat and 15% protein, or within recommended AMDR ranges. BN’s micronutrient intake reflect low calcium (40% RDA), vitamin D (3% RDA), potassium (36% AI) and marginally high iron intake (114% RDA).
Case 2
CE is a 27 year-old transgender male. He gained 40 lbs. when starting hormone therapy 18 months ago. CE reported that he “tried really hard for like, about 6-8 months to lose it, and then I was getting nowhere. So, I just kind of gave up.” He also described himself as a picky eater and “weird about textures,” but that he is starting to try new foods that his boyfriend prepares.
He has a BMI of 33 kg/m2, body fat percentage of 34% and waist circumference of 41 in., indicating obesity class I and central adiposity. He has a low risk of eating disorders (6/26 on the EAT-26) and yet a low degree of eating competence (24/48 on the ecSI-2). CE’s dietary pattern includes 2–4 eating instances per day at home and work. He consumes 0–1 servings of vegetables per day and a high intake of added sugars in the form of sodas, iced coffees and energy drinks.
His diet analysis was characterized by low energy (74% kcal needs), appropriate saturated fat intake (10% kcal intake), low fiber (41% AI), and high sodium (206% DGAs limit). His macronutrient intake was 63% carbohydrate, 23% fat and 14% protein, or within recommended AMDR ranges. CE’s micronutrient intake reflected adequate calcium (105% RDA), low vitamin D (48% RDA), low potassium (40% AI), and marginally low iron (84% RDA).
Case 3
VK is a 29 year-old transgender male and has been on hormone therapy for 5 years. He noted that although he has “always struggled with food and weight and body image,” that his relationship with food and exercise started improving when he came out. He now approaches food as “more of a tool and a strengthening thing.”
VK has a BMI of 35 kg/m2, body fat percentage of 35% and waist circumference of 40 in., indicating obesity class II and central adiposity. He has a low risk of eating disorders (16/26 on the EAT-26) and yet a low degree of eating competence (30/48 on the ecSI-2). His dietary pattern includes 4–5 eating instances per day at home and fast food restaurants. VK consumes 2–3 servings of fruits and vegetables daily and added sugars in the form of sweetened coffee drinks and energy bars.
VK’s diet analysis was characterized by low energy (58% kcal needs), high saturated fat (29% kcal intake), low fiber (32% AI), and marginally high sodium (117% DGAs limit). His macronutrient intake was 21% carbohydrate, 55% fat and 24% protein, or lower in carbohydrate and higher in fat than the AMDR ranges. VK’s micronutrient intake reflected high calcium (124% RDA), low vitamin D (7% RDA), low potassium (16% AI) and adequate iron (102% RDA).
Case 4
MR is a 30 year-old transgender male and has been on hormone therapy for just over 1 year. He reported gaining 15 lbs. of mostly muscle mass during the first 2 months of hormone therapy and then losing weight after a reconstructive chest surgery, or top surgery. He notes, “I don’t necessarily want to be thinner.” MR is somewhat conscientious of his kcal intake but is primarily driven by the feeling: “I still want to have a lot of fun, and I want to be myself.”
He has a BMI of 25 kg/m2, body fat percentage of 19% and waist circumference of 32 in., indicating an overweight BMI and yet overall healthy body weight and composition given the additional anthropometric measures. He has a low risk of eating disorders (3/26 on the EAT-26) and yet a low degree of eating competence (29/48 on the ecSI-2). MR’s follows a mostly vegetarian dietary pattern with 3–4 eating instances per day at home and at restaurants. He consumes 2–3 servings of vegetables and fruits daily, very little added sugars, and 1–4 alcoholic drinks/day.
MR’s diet analysis was characterized by marginally low energy (84% kcal needs), appropriate saturated fat (8% total kcals), low fiber (71% AI), and high sodium (134% DGAs limit). His macronutrient intake was 32% carbohydrate, 33% fat, and 22% protein, or lower in carbohydrate than the AMDR ranges. Additionally, 13% of his kcals were derived from alcohol. MR’s micronutrient intake reflected high calcium (132% RDA), low vitamin D (53% RDA), low potassium (47% AI) and high iron intake (171% RDA).
Case 5
CA is a 31 year-old transgender male. He started hormone therapy and had top surgery over 3 years ago. CA was motivated to lose weight in order to be eligible for top surgery, but didn’t feel comfortable going to the gym without wearing a binder, or a compression undershirt worn to flatten breasts, which he knew was not safe. CA also had gastric sleeve surgery after his top surgery “just because I wanted to take care of my health more.” He notes, “I feel like I made the right choice in doing top surgery first, and then that lead me to take care of myself more.”
CA has a BMI of 33 kg/m2, body fat percentage of 41% and waist circumference of 44 in., indicating class I obesity and central adiposity. He has a low risk of eating disorders (3/26 on the EAT-26) and yet a low degree of eating competence (23/48 on the ecSI-2). He follows a vegetarian dietary pattern with 5–6 eating instances per day at home and fast food restaurants. CA consumes 2–3 servings of fruits and vegetables daily and added sugars in the form of breakfast cereals, muffins, and sweetened tea.
CA’s diet analysis was characterized by low energy (77% kcal needs), marginally high saturated fat (13% total kcals), low fiber (69% AI) and high sodium (154% DGAs limit). His macronutrient intake was 47% carbohydrate, 37% fat and 15% protein, or slightly higher in fat than the AMDR ranges. CA’s micronutrient intake reflected adequate calcium (90% RDA), low vitamin D (11% RDA), low potassium (15% AI) and high iron (199% RDA).
Case 6
GT is a 32 year-old transgender male. He has been on hormone therapy for over 10 years and recalls initially gaining approximately 40 lbs., which he lost slowly over time. GT and his partner are now into ayurvedic cooking, though he still enjoys “going to get a burger across the street.” GT is physically active with drumming, biking and rock climbing.
He has a BMI of 25 kg/m2, body fat percentage of 15% and waist circumference of 35 in., indicating an overweight BMI and yet overall healthy body weight and composition given the additional anthropometric measures. He has a low risk of eating disorders (2/26 on the EAT-26) and yet a low degree of eating competence (30/48 on the ecSI-2). GT’s dietary pattern includes 5–7 eating instances per day at home, a friend’s home, or restaurants. He consumes 3–6 servings of fruits and vegetables daily and sugar-sweetened foods and beverages in the form of coffee drinks, cookies and candy. His beverage intake also includes 0–4 alcoholic drinks per day.
GT’s diet analysis was characterized by marginally high energy (119% kcal needs), marginally high saturated fat (14% total kcals), low fiber (59% AI) and high sodium (221% DGAs limit). His macronutrient intake was 43% carbohydrate, 36% fat and 16% protein, or slightly lower in carbohydrate and higher in fat than the AMDR ranges. Additionally, 5% of his kcals were derived from alcohol. GT’s micronutrient intake reflected adequate calcium (98% RDA), low vitamin D (3% RDA), marginally low potassium (89% DI) and high iron (263% RDA).
Case 7
CM is a 33 year-old transgender male and has been on hormone therapy for over 5 years. He experienced an initial weight gain of approximately 60 lbs., both due to an increase in appetite and a genuine desire to have a larger body size. He describes this as, “I’m not going to blow over and am just more rugged, solid, stocky.”
CM has a BMI of 51 kg/m2, body fat percentage of 46% and waist circumference of 57 in., indicating class III obesity and central adiposity. He has a low risk of eating disorders (12/26 on the EAT-26) and a high degree of eating competence (35/48 on the ecSI-2). CM’s dietary pattern includes 5–6 eating instances per day at home, work, or fast food restaurants. He consumes 1–2 servings of vegetables per day and added sugars in the form of candy, energy drinks, and ice cream. His beverage intake also includes 0–2 alcoholic drinks per day.
CM’s diet analysis was characterized by adequate energy (102% kcal needs), marginally high saturated fat (14% total kcals), low fiber (71% AI) and high sodium (228% DGAs limit). His macronutrient intake was 42% carbohydrate, 41% fat and 15% protein, or lower in carbohydrate and higher in fat than the AMDR ranges. Additionally, 2% of his kcals were derived from alcohol. CM’s micronutrient intake reflected high calcium (167% RDA), low vitamin D (11% RDA), low potassium (37% AI) and high iron (149% RDA).
Case 8
SB is a 37 year-old transgender male and has been on hormone therapy for just over 1 year. He was highly motivated to improve his diet prior to starting hormone therapy. He noted, “… the things I was able to eat, in my mind, were helping me to get ready for the medical transition.” He had also sought out foods that had been purported to increase natural levels of testosterone, though he noted he doesn’t know if they actually worked or simply helped him to feel more mentally prepared.
SB has a BMI of 21 kg/m2, body fat percentage of 13% and waist circumference of 31 in., indicating a healthy body weight and body composition. He has a low risk of eating disorders (7/26 on the EAT-26) and a high degree of eating competence (48/48 on the ecSI-2). SB follows a gluten-free dietary pattern with 4–7 eating instances per day at home or work. He consumes 2–4 servings of fruits and vegetables per day and minimal added sugars in any form.
SB’s diet analysis was characterized by adequate energy (109% kcal needs), appropriate saturated fat (7% total kcals), low fiber (75% AI) and high sodium (169% DGAs limit). His macronutrient intake was 44% carbohydrate, 38% fat and 18% protein, or slightly lower in carbohydrate and higher in fat than the AMDR ranges. SB’s micronutrient intake reflected low calcium (53% RDA), low vitamin D (20% RDA), low potassium (39% AI) and high iron (197% RDA).
Case 9
CJ is a 49 year-old transgender male and has been on hormone therapy for over 11 years. CJ’s diet or physical activity level has not changed over the years in relation to his transition. He comments, “I don’t think transitioning has changed anything about the way I eat, really.” Rather, his diet fluctuates more so in relation to his income and employment benefits.
CJ has a BMI of 31 kg/m2, body fat percentage of 30% and waist circumference of 42 in., indicating obesity class I and central adiposity. He has a low risk of eating disorders (2/26 on the EAT-26) and yet a low degree of eating competence (26/48 on the EAT-26). CJ’s dietary pattern includes 3–4 eating instances per day at home, restaurants, or in his car. He consumes 0–3 servings of fruits and vegetables per day and added sugars in the form of candy, pastries, cookies, and coffee drinks. His beverage intake also includes low carbohydrate energy drinks.
CJ’s diet analysis was characterized by marginally high energy (112% kcal needs), high saturated fat (18% total kcals), low fiber (49% AI) and high sodium (205% DGAs limit). His macronutrient intake was 38% carbohydrate, 50% fat and 12% protein, or lower in carbohydrate and higher in fat than the AMDR ranges. CJ’s micronutrient intake reflected marginally high calcium (111% RDA), low vitamin D (3% RDA), low potassium (18% AI) and high iron (158% RDA).
Case 10
GJ is a 51 year-old transgender male and has been on hormone therapy for 7 years. His diet has not changed much throughout his transition. He notes, “It’s pretty much been the same throughout.” GJ points out that much of the LGBT social community is centered around bars and that “you end up having a lot of calories of alcohol … if you center around a bar, you know, your eating habits and drinking habits are not the greatest.”
He has a BMI of 39 kg/m2, body fat percentage of 34% and waist circumference of 44 in., indicating obesity class II and central adiposity. He has a low risk of eating disorders (8/26 on the EAT-26) and yet a low degree of eating competence (23/48 on the EAT-26). GJ’s dietary pattern includes 3–4 eating instances per day. He consumes 0–2 servings of vegetables per day and sugar-sweetened foods and beverages in the form of soda and cookies. His beverage intake also includes 0–3 alcoholic drinks per day.
GJ’s diet analysis was characterized by adequate energy (109% kcal needs), appropriate saturated fat (7% total kcals), low fiber (39% AI) and high sodium (155% DGAs limit). GJ’s macronutrient intake was 64% carbohydrate, 24% fat and 8% protein, or slightly lower in protein than the AMDR ranges. Additionally, 4% of his kcals were derived from alcohol. GJ’s micronutrient intake reflected low calcium (22% RDA), low vitamin D (0% RDA), low potassium (9% AI) and low iron (70% RDA).