What are the considerations for nutrition assessment when working with transgender and gender-diverse (TGD) individuals?

Sign in Start free trial

Key Practice Points

Assessment

Q: What are the considerations for nutrition assessment when working with transgender and gender-diverse (TGD) individuals?

Last Updated: 2023-09-20

Search Strategy Contributors

Key Practice Point #1: Nutrition-related Health Effects

Recommendation

Health care professionals should assess and manage cardiovascular risk and bone health in TGD individuals, considering length and dose of hormone use, current age and the age at which hormone therapy was started, given the risks associated with gender-affirming hormone therapy (GAHT).

Individuals receiving gender-affirming testosterone-based therapy may experience weight gain, increased lean mass, decreased fat mass, increased hemoglobin, hematocrit and creatinine levels, and delayed prothrombin time. These individuals likely have an increased risk for polycythemia, hypertension and a possible increased risk for dyslipidemia, cardiovascular disease (CVD) and type 2 diabetes.

Individuals receiving gender-affirming estrogen-based therapy are likely to have an increased risk of weight gain, thromboembolism, hyperkalemia, decreased creatinine levels, hypertriglyceridemia and a possible increased risk for CVD, cholelithiasis and type 2 diabetes. Individuals may experience an increased risk of low bone mass/osteoporosis or an increase in bone mineral density (BMD), particularly if they have undergone gender-affirming genital surgery with gonad removal.

Nutrition counselling of TGD individuals with health conditions is similar to the management in other adult populations. Strategies to promote person-centred and inclusive care are recommended for TGD individuals.

See Additional Content: Food, Nutrition and Eating Issues of Transgender and Gender-diverse Individuals Background.

Evidence Summary

A 2020 scoping review identified 139 studies reporting intermediate and long-term health effects of hormone therapy. For adults treated with masculinizing or feminizing hormone therapy, the most frequently reported outcomes relate to anthropometric measures, lipid profiles, bone density, cardiovascular events, cancer and mortality. For adolescents treated with puberty blockers, anthropometric measures and bone density were reported frequently. The authors suggested that these findings be used to guide practice decisions when providing care for TGD individuals and to support future research addressing appropriate and effective nutrition interventions related to health outcomes for transgender individuals.
Grade of Evidence C

A 2019 practice paper from the Academy of Nutrition and Dietetics (AND) identified a number of nutrition-related clinical considerations of individuals who are transgender, including an increased risk of polycythemia (in transgender males) and an increased risk of venous thromboembolic disease and hypertriglyceridemia in transgender females.
Grade of Evidence B

Individuals receiving gender-affirming testosterone-based therapy may experience weight gain; increased lean mass; decreased fat mass; increased LDL lipoprotein, hemoglobin, hematocrit and creatinine levels; decreased HDL lipoprotein and delayed prothrombin time Grade of Evidence C. Individuals receiving gender-affirming estrogen-based therapy may experience variable changes in HDL and LDL levels and blood pressure, an increase in BMD (particularly if they have undergone gender-affirming genital surgery with gonad removal) and decreased creatinine levels. A possible increased risk of cardiovascular disease, hypertension and type 2 diabetes was also identified in adults receiving GAHT. The AND identified the important role of dietitians in nutrition counselling of transgender clients with health conditions, as with management in other adult populations.
Grade of Evidence C

Recommendations from the 2022 standards of care from the World Professional Association for Transgender Health (WPATH) are that health care professionals assess and manage cardiovascular health in TGD individuals, considering the length and dose of hormone use, current age and the age at which hormone therapy was started, based on studies suggesting increased risks with the following regimens:

Individuals receiving testosterone-based regimens are likely to have an increased risk of polycythemia, hypertension, weight gain, decreased HDL-cholesterol and increased LDL-cholesterol levels Grade of Evidence B. With additional risk factors present, there is also likely an increased risk of CVD and hypertriglyceridemia, and a possible increased risk of type 2 diabetes Grade of Evidence C.
Individuals receiving estrogen-based regimens are likely to have an increased risk of thromboembolism, hyperkalemia, hypertriglyceridemia and weight gain and a possible increased risk of hypertension Grade of Evidence B. With additional risk factors present, there is also likely an increased risk of CVD and cholelithiasis, and a possible increased risk of type 2 diabetes and low bone mass/osteoporosis Grade of Evidence C.

Prior to initiating GAHT, the guidelines also recommend discussing bone health with TGD individuals, including recommendations to prevent osteoporosis relevant to all populations (i.e. the importance of weight-bearing exercise, healthy diet, adequate calcium and vitamin D supplementation in high risk groups (e.g. those with prior fracture, high risk medications, conditions associated with bone loss and low body weight or if hypovitaminosis D is identified)).
Grade of Evidence C

Remarks

Stigmatization and limited access and utilization of health care services can be contributing factors to adverse health outcomes.

See Additional Content:

Cardiovascular Disease Knowledge Pathway

Cardiovascular Disease - Dyslipidemia Knowledge Pathway

Cardiovascular Disease - Hypertension Knowledge Pathway

Diabetes/Glucose Intolerance Knowledge Pathway

Bone Health and Osteoporosis Knowledge Pathway

Weight/Obesity Knowledge Pathway

Weight-Inclusive Approach Background.

A scoping review (from 1999 to December 2019) describing the nutrition-related intermediate and long-term health outcomes in individuals who are transgender identified 189 studies, including 146 peer-reviewed studies (primarily cohort, cross-sectional and case-control), 33 conference abstracts and eight registered trials (1). The review followed the PRISMA scoping checklist and summarized 139 studies that examined the following reported health outcomes of hormone therapy:
- Adolescents Treated with Puberty Blockers (21 studies): the most frequently reported intermediate outcomes included anthropometric measures and bone density; health outcomes were rarely reported.
- Adults Treated with Masculinizing (100 studies) or Feminizing Hormone Therapies (85 studies): the most frequently reported outcomes were related to anthropometric measures, lipid profiles and bone density; long-term health effects included cardiovascular events, cancer and mortality.
- Nutrition Interventions: Two uncontrolled trials examined effects of vitamin D taken with GAHT on anthropometrics, biochemistry and bone density.
- No studies examined nonbinary subjects.

The authors concluded that due to the lack of research related to nutrition assessment methods and nutrition interventions, guidelines for delivering the nutrition care process to the transgender community are needed (1). Studies evaluating the appropriateness and effectiveness of different nutrition interventions are also needed. Limitations of this review are the absence of qualitative studies and exclusion of studies that did not have a comparative population to reference, which may have resulted in a lower reporting of some outcomes.

A 2019 practice paper from the AND examining the nutrition-related clinical considerations of transgender individuals identified several observational studies reporting (2):
- Individuals receiving gender-affirming testosterone-based therapy may experience weight gain, increased lean mass, decreased fat mass, increased LDL lipoprotein, hemoglobin, hematocrit and creatinine levels and decreased HDL lipoprotein and delayed prothrombin time (2). The practice paper cites the 2012 World Professional Association for Transgender Health (WPATH) standards of care that reports that transgender males are likely to have an increased risk for polycythemia (elevated concentration of red blood cells), and a possible increased risk for dyslipidemia, cardiovascular disease, hypertension and type 2 diabetes (3).
- Individuals receiving gender-affirming estrogen-based therapy may experience variable changes in HDL and LDL levels and blood pressure, an increase in BMD, particularly if they have undergone gender-affirming genital surgery with gonad removal, and decreased creatinine levels. The WPATH identified transgender females as likely to have an increased risk for venous thromboembolic disease and hypertriglyceridemia and a possible increased risk for hypertension and type 2 diabetes (3).

The AND paper identified the important role of dietitians in nutritional counselling of transgender clients with chronic conditions similar to the management in other adult populations; however, a barrier to management is the stigmatization of transgender individuals and limited access and utilization of health care services by transgender individuals, all of which can contribute to adverse health outcomes. The AND supports best practice guidelines published by the Joint Commission (4) designed to promote patient-centered and inclusive care for the LGBTQ community (3).

The 2022 standards of care for the health of TGD individuals developed by WPATH (updated from the standards cited in the AND review (3)) identifies risks associated with GAHT and provides a specific nutrition recommendation related to bone health (5).
- Risk Assessment: The guidelines recommend that health care professionals assess and manage cardiovascular health in TGD individuals, considering the length and dose of hormone use, current age and the age at which hormone therapy was started, based on studies suggesting increased risks with the following regimens:
  - Individuals receiving testosterone-based regimens are likely to have an increased risk of polycythemia, hypertension, weight gain, decreased HDL-cholesterol and increased LDL-cholesterol levels. With additional risk factors present, there is also likely an increased risk of CVD and hypertriglyceridemia, and a possible increased risk of type 2 diabetes.
  - Individuals receiving estrogen-based regimens are likely to have an increased risk of thromboembolism, hyperkalemia, hypertriglyceridemia and weight gain, and a possible increased risk of hypertension. With additional risk factors present, there is also likely an increased risk of CVD and cholelithiasis, and a possible increased risk of type 2 diabetes and low bone mass/osteoporosis.
- Nutrition Recommendation for Bone Health: The guidelines identify two case-control studies reporting low BMD before the initiation of hormones in both adults and adolescents and one study reporting acceleration of bone loss after gonadectomy when hormones were stopped or hormone levels were suboptimal. Several observational studies reported TGD individuals receiving estrogen therapy had improvements in BMD. Osteoporosis screening recommendations in TGD individuals are typically before initiating GAHT and continued screening in the presence of traditional risk factors (e.g. prior fracture, high risk medications, conditions associated with bone loss and low body weight). Two observational studies reported a high prevalence of hypovitaminosis D in TGD populations. WPATH recommends that health care professionals discuss bone health with TGD individuals, including the importance of weight-bearing exercise, a healthy diet and adequate calcium and vitamin D supplementation (amount not specified) in high risk groups or if hypovitaminosis D is identified.

Key Practice Point #2: Nutrition Assessment

Recommendation

The following approaches are suggested for nutrition assessment when working with TGD individuals (See Remarks):

For Those Who Are Not Medically Transitioning (includes adolescents on pubertal suppression therapy and adolescents/adults who have not received gender-affirming hormone therapy (GAHT) or surgical interventions): Use reference values consistent with the person’s sex assigned at birth.
For Those Who Are Medically Transitioning with Hormone Therapy (HT) (which may also include transition-related surgery): Individualize nutrition assessment to align with the medical transition (e.g. duration of GAHT, low-to-moderate GAHT regimens), especially related to anticipated physical changes with GAHT (e.g. body fat %, waist circumference, waist-to-hip ratio), interpret laboratory values (e.g. iron status) and determine nutrient recommendations (e.g. fibre, iron, zinc).
- For individuals on masculinizing HT, increased muscle mass/strength can begin at six to 12 months with a maximum effect at two to five years.
- For individuals on feminizing HT, decreased muscle mass/strength can begin at three to six months with a maximum effect at one to two years.
For Individuals on GAHT for a Short Time (<6 months) or on Low-to-moderate GAHT Regimens (e.g. low-dose testosterone therapy): Express data as a range between female and male reference values, especially for protein and energy needs, which reflect a range of values.

Evidence Summary

The recommendations are based on a 2022 practice paper from the Academy of Nutrition and Dietetics (AND) that examined nutrition assessment parameters utilizing sex-specific data and how they can be individualized for TGD clients based on medical transition.

Grade of Evidence C

Remarks

Some aspects of nutrition assessment are sex-specific and can pose challenges in applying to TGD individuals. It can be helpful to explain to an individual when a reference intake is used based on sex assigned at birth without gendering the recommendation. Practitioners can consider other physiologic factors that may affect nutrient recommendations (e.g. whether or not the client is menstruating). Despite the use of sex-specific reference values, practitioners can use other ways to ensure a person’s gender identity is still being affirmed in these instances, such as the use of one’s chosen name and pronouns.

Given the interrelated social and psychological challenges experienced by TGD individuals, practitioners are encouraged to consider the various sources of stigma (including weight stigma) experienced by each individual and take action toward providing gender-affirming nutrition care.

See Additional Content:

Food, Nutrition and Eating Issues of Transgender and Gender-diverse Individuals Background.

Weight Stigma Background.

A practice paper from the Academy of Nutrition and Dietetics (AND) described nutrition assessment as it relates to biological sex and suggested approaches for dietetics practitioners when working with TGD clients (1). The following nutrition assessment parameters within the nutrition care process that utilize sex-specific data for interpretation were identified:
- Food/nutrition-related History: predictive equations for energy needs, dietary reference intake values for nutrient recommendations
- Anthropometric Measures: body fat percentage, waist circumference, waist:hip ratio and BMI-for-age percentiles
- Biochemical Data, Medical Tests: HDL-cholesterol, cholesterol:HDL ratio, hemoglobin, hematocrit, red blood cell count, ferritin, creatinine, alkaline phosphatase, bone mineral density
- Nutrition-focused Physical Findings: client medical history, assessment, monitoring and evaluation tools do not have data points with sex-specific reference ranges.

Based on these parameters, the following approaches for nutrition assessment of TGD clients were suggested:

For Clients Who Have Not Medically Transitioned (includes adolescents on pubertal suppression therapy and adolescents/adults who have not received HT or surgical interventions): Use reference values consistent with the client’s sex assigned at birth.
For Clients Who Have Medically Transitioned: Individualize nutrition assessment to align with the medical transition. This is particularly relevant to the use of reference values relevant to anticipated physical changes with HT (e.g. body fat %, waist circumference, waist-to-hip ratio) and interpreting laboratory values (e.g. iron status related to menstruation or not). The AND paper cites the World Professional Association for Transgender Health Guidelines that specify the expected time of onset and maximum effect with masculinizing and feminizing HT (2). As example, for clients on masculinizing HT, increased muscle mass/strength can begin at six to 12 months with a maximum effect at two to five years; on feminizing HT, decreased muscle mass/strength can begin at three to six months with a maximum effect at one to two years (1). Individualizing nutrition assessment also takes into consideration that some clients may seek only moderate changes with HT or choose a combination of masculine and feminine sex characteristics.
For Clients on HT for a Short Time (<6 months) or on Low-to-moderate-HT Regimens: Express data as a range between female and male reference values especially for protein and energy needs, which reflect a range of values (1). Low-to-moderate-HT regimens (typically testosterone) are used for clients who desire limited or slower hormone effects; testosterone can be started at low doses and advanced slowly to achieve effect (3).

Contributors

Current Contributors

Catherine Morley

Co-Author

Co-Author

Co-Author

Reviewer

Kathleen Halliday

Reviewer

Reviewer

Reviewer