Clinical Nutrition ESPEN xxx (xxxx) xxx

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Clinical Nutrition ESPEN

journal homepage: http://www.clinicalnutritionespen.com

Meta-analysis

Hormone therapy, health outcomes and the role of nutrition in

transgender individuals: A scoping review
M. Rozga a, *, W. Linsenmeyer b, J. Cantwell Wood c, 1, V. Darst d, E.K. Gradwell e
a
Academy of Nutrition and Dietetics, 120 S. Riverside Plaza, Suite 2190, Chicago, IL, 60606-6995, USA
b
Saint Louis University, Department of Nutrition and Dietetics, 3437 Caroline Street, Room 3076, St. Louis, MO, 63104, USA
c
Nunnelee Pediatrics Specialty Clinic, New Hanover Regional Medical Center, 510 Carolina Bay Drive, Suite 200, Wilmington, NC, 28403, USA
d
Children's Hospital Los Angeles Division of Adolescent and Young Adult Medicine, 1200 Dallas Dr, Apt 113, Denton, TX, 76205, USA
e
Academy of Nutrition and Dietetics, 7558 Harlan Street, Arvada, CO, 80003, USA

a r t i c l e i n f o s u m m a r y

Article history: Objective: The objective of this scoping review is to describe the extent, range, and nature of available
Received 6 June 2020 literature examining nutrition-related intermediate and long-term health outcomes in individuals who
Accepted 22 August 2020 are transgender. Specific sub-topics examined include 1) dietary intake, 2) nutrition-related health
disparities, 3) validity and reliability of nutrition assessment methods, 4) the effects of nutrition in-
Keywords: terventions/exposures, and 5) hormone therapy.
Transgender persons
Methods: A literature search was conducted using MEDLINE, Embase, PsycINFO, CINAHL, Web of Science,
Health services for transgender persons
and other databases for peer-reviewed articles published from January 1999 until December 5, 2019 to
Diet
Food and nutrition
identify studies addressing the research objective and meeting eligibility criteria. Conference abstracts
Nutrition assessment and registered trials published or registered in the five years prior to the search were also included.
Gender dysphoria Findings were reported in a study characteristics table, a bubble chart and heat maps.
Scoping review Results: The search of the databases identified 5403 studies, including full peer-reviewed studies, systematic
reviews, conference abstracts and registered trials. Following title/abstract screening, 189 studies were
included in the narrative analysis. Ten studies reported dietary intake in transgender individuals, 64 studies
reported nutrition-related health disparities in transgender compared to cisgender individuals, one study
examined validity and reliability of nutrition assessment methods, two studies reported nutrition in-
terventions, and 127 studies reported on the intermediate and health effects of hormone therapy.
Conclusion: Individuals who are transgender have unique nutrition needs, which may vary according to
the stage and type of gender-affirmative therapy that they are undergoing. There is scant research
examining effective nutrition therapy methods for nutrition professionals working with transgender
individuals. More research is needed in order to inform evidence-based clinical practice guidelines for
nutrition practitioners working with transgender individuals.
© 2020 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
reserved.

1. Introduction Particular areas of concern for the transgender population may

include: disordered eating second to body dissatisfaction; disparate
The unique nutrition needs of individuals who are transgender health outcomes associated with gender-based stigma, discrimi-
have been increasingly recognized by professional nutrition orga- nation, and lack of access to healthcare; and potential nutrition-
nizations [1,2]. While there are current guidelines to inform med- related side effects related to gender-affirmative therapies and
ical and psychological care for transgender individuals [3,4], there surgery, including hormone therapies. Recent guidance on nutri-
are no systematic reviews or evidence-based practice guidelines to tion care for individuals who are transgender has focused on
guide nutrition professionals working with transgender clients. providing culturally sensitive care in a safe environment [1,2]. This
guidance includes the recognition and use of culturally appropriate
* Corresponding author. language and counseling techniques, and the recognition that the
E-mail addresses: mrozga@eatright.org (M. Rozga), whitney.linsenmeyer@ use of gender-affirmative therapy may minimize harm within the
health.slu.edu (W. Linsenmeyer), jennifer.cantwellwood@nhrmc.org,
context of healthcare. There is a dearth of transgender-specific
familynutritionofthetriad@gmail.com (J. Cantwell Wood), vaughn@
allgendernutrition.com (V. Darst), ericagradwell@yahoo.com (E.K. Gradwell). research to guide nutrition practitioners on appropriate and
1
Current affiliation and information: Family Nutrition of the Triad, LLC Address: effective nutrition screening, assessment and interventions.
212 Sir Richard Ln., Chapel Hill, NC, 27517, USA.
https://doi.org/10.1016/j.clnesp.2020.08.011
2405-4577/© 2020 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
2 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx

Table 1
Eligibility criteria for scoping review examining hormone therapy, health outcomes and the role of nutrition in transgender individuals.

Inclusion Criteria Exclusion Criteria

Peer-Review Status Peer-reviewed articles published in a juried publication in a peer- Non-peer-reviewed articles such as government reports or position
reviewed section within the publication; published conference statements.
abstracts; registered trials
Population ∙Humans ∙Animal studies
∙Individuals who are transgender ∙Populations including but not limited to transgender individuals
∙Adults (
18 years old) (ex: Population is LGBTQ, but no information on the transgender
∙Children/adolescents (<18 years) sub-group alone).
Setting Any setting None excluded
Health Status Open None
Interventions/Exposures ∙Dietary Intake ∙Non nutrition-related exposures or interventions
∙Validity/reliability of nutrition assessment methods ∙Effects of surgery
∙Nutrition exposures/interventions ∙Description of weight-based victimization
∙Hormone therapy
Comparators Q2: must compare to cisgender population Q2: does not compare prevalence to a cisgender population
Q5a: must compare measurements before and after treatment Q5a: does not report before and after measurements
Study Design Preferences ∙Clinical trials (RCTs, NRCTs, non-controlled trials); Observational ∙Narrative reviews
studies (cross-sectional, cohort, caseecontrol, case studies); ∙Articles that do not report primary studies such as editorials,
∙Qualitative Studies; Systematic reviews and meta-analyses letters to the editor, etc.
∙Q1 and Q2: Cohort or cross-sectional studies ∙Cross-sectional studies are excluded for Q5a
∙Q3: Validity and reliability studies
∙Q4: Clinical trials (RCTs, NRCTs, non-controlled trials);
Observational studies (cross-sectional, cohort, caseecontrol, case
studies);
∙Qualitative Studies; Systematic reviews and meta-analyses
Q5a: Trials, cohort studies or single-armed (or greater) trials.
Minimum Study Duration Open Open
Size of Study Groups ∙
10 participants for quantitative studies reporting intermediate ∙<10 participants for quantitative studies reporting intermediate
outcomes outcomes
∙
3 participants for qualitative studies ∙<3 participants for qualitative studies
∙
100 participants for health outcomes (Q2, Q5b) ∙<100 participants for health outcomes (Q2, Q5b)
Study Drop Out Rate Open Open
Outcomes ∙Q1: Dietary intake ∙Non nutrition-related outcomes
∙Q2: Health outcomes ∙Q2: Intermediate outcomes
∙Q3: Validity/Reliability measures
∙Q4: Intermediate and health outcomes
∙Q5a: Intermediate outcomes
∙Q5b: Health outcomes
Intermediate Outcomes include: Dietary intake, anthropometrics,
nutrition-related lab values
Health Outcomes include: a) mortality, b) osteoporosis/osteopenia,
c) diabetes, d) cardiovascular disease, e) hypertension, f) metabolic
syndrome, g) overweight/obesity/underweight, h) eating disorders,
i) food insecurity, j) Quality of Life, k) alcohol abuse
Year Range 1999e2019 Prior to 1999; after search date of December 5, 2019
Language Limited to articles in English Articles not published in English

Finally, there is minimal data that examines variance in nutri-
tional needs for subpopulations within the transgender commu-
nity, particularly for individuals who do not choose to undergo
medical transition or who opt for “low-dose” hormone replace-
ment therapies. Existing standards of practice in transgender
medicine have focused on medical intervention and mental health
priorities, with a lack of attention paid to the role of the dietitian in
providing gender affirmative nutrition care [1,2]. Thus, a scoping
review of the available literature regarding nutrition-related topics
for the transgender population may serve as a first step towards
informing evidence-based practice.
The objective of this scoping review is to describe the extent,
range and nature of the available literature examining the
nutrition-related intermediate and long-term health outcomes in
individuals who are transgender. Specific sub-topics examined
include 1) dietary intake, 2) nutrition-related health disparities, 3)
validity and reliability of nutrition assessment methods, 4) the ef-
fects of nutrition interventions/exposures, and 5) hormone therapy.
2. Methods
The scoping review process followed the framework developed
by Arskey and O'Malley [5] and later refined by Levac et al. [6] and
the Joanna Briggs Institute [7] and adheres to the PRISMA scoping
review checklist [8]. The research team included an information
specialist; two RDNs with experience in research methodology;
and three RDNs with experience in nutrition counseling with
transgender individuals who were recruited as content experts to
inform the development of the research question and sub-
questions, eligibility criteria, and data interpretation. One of these
content experts is non-binary transgender and serves as a com-
munity leader in transgender-centered dietetics. The second is an
RDN who works in community nutrition and is the parent of a
transgender child. The third is an assistant professor of nutrition
with a research focus on nutrition care for the transgender popu-
lation. The protocol for this scoping review was registered at Open
Science Framework (https://osf.io/dqwfj) [9].
2.1. Eligibility criteria
Eligibility Criteria was specified a priori according to the Popu-
lation, Concept, Context (PCC) approach for scoping reviews
(Table 1) [7]. The eligibility criteria specified that the “population”
must identify as transgender (or use another analogous term), or as
a related sub-population, as identified by content experts. For the
purpose of this review, “transgender” is used as a broad umbrella

Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx 3

Fig. 1. PRISMA Flow Diagram describing the inclusion of studies in a scoping review examining hormone therapy, health outcomes and the role of nutrition in transgender
individuals.

Fig. 2. Bubble chart of included studies by sub-question according to year of publication in the transgender nutrition scoping review (2002e2019)a.
a
This scoping review searched databases from 1999-2019, but data was 1999-2001 is not represented in this bubble chart.

Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
4 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx

Table 2
Included Studies Describing Dietary Intake in Individuals who are Transgender.

Study Population Description Age Group Hormone Status Sample Size Dietary Intake Measure

Bryn Austin et al. 2016 Gender non-conforming Adolescents and adults Unclear 350 Breakfast
[32] Family dinner
Prospective cohort Fast food
Sugar sweetened beverages
Corte et al. 2016[42] Trans Adolescents and adults Unclear 21 Alcohol (number of drinks/day
Cross-sectional in last 90 days)
Olson-Kennedy et al. Transgender Children and adolescents Puberty blockers (GnRH 391 Calcium intake
2019[137] agonists) followed by
Prospective cohort masculinizing and
(protocol only) feminizing hormones
Smalley et al. 2016 Transgender, genderqueer, Adults Unclear 325 Alcohol (more than 5 drinks at a
[155] nonbinary 82 females, 126 males, time)
Cross-sectional and 117 genderqueer, Caloric beverages
non-binary or other Eating when not hungry
Fried foods
Fruits and vegetables
Skipping meals
Tupler et al. 2017[165] Transgender Adolescents and adults Unclear 989 Alcohol (total number of drinks
Cross-sectional and number of drinking days in
past two weeks, maximum
number of drinks on any single
day)
Van Velzen et al. 2019 Transgender Adults Masculinizing and 430 Alcohol (units/week)
[175] feminizing hormones 188 transmen and 242
Prospective cohort transwomen
VanKim, Corliss et al. Gender non-conforming Adolescents and adults Unclear 172 Alcohol (drinks/day)
2019[179] Breakfast
Prospective cohort Energy intake
Family dinner
Fat types
Fruits and vegetables
Mothers AHEI-2010 score
Nuts and legumes
Red/processed meat
Sodium intake
Sugar sweetened beverages and
fruit juice
Whole grains
VanKim, Erickson et al. Transgender Adults Unclear 53 Breakfast
2014[178] Fast food
Cross-sectional Fruits and vegetables
Restaurant food
Soda and diet soda
Vilas et al. 2014[177] Gender dysphoria Adults Masculinizing and 157 Breakfast
Prospective cohort feminizing hormones Carbohydrate intake
Cholesterol intake
Eat outside of the home
Energy intake
Fat intake (total, SFA, MFA, PFA)
Fiber intake
Meal/snack consumption
Protein intake
Vitamin and mineral intake
Vlot et al. 2019[182] Transgender Adults Masculinizing and 253 Alcohol (units/week)
Prospective cohort feminizing hormones 121 transwomen and
132 transmen

term referencing any and all individuals whose gender identity
does not align with their sex assigned at birth. This umbrella can
include individuals who identify as transgender, non-binary,
transmasculine, transfeminine, genderqueer, gender non-
conforming, gender diverse, genderfluid, agender, etc. There were
no limits on participant age. Content advisors and the information
specialist collaborated to create a comprehensive list of terms that
could be used to identify the population of interest, such as
“transgender”, “gender non-binary” or “gender non-conforming”
(please see Supplement 1 for search terms). The “Concept” was
nutrition-related assessment methods, interventions, exposures
and outcomes; there were no limits on “context”. Articles were
searched from 1999 (20 years at the time of the search) per the
suggestion of content advisors who advised that literature before
that date would be outdated. Articles were limited to the English
language due to resource constraints. While the team identified
outcomes of interest a priori, the outcome category was left open to
all nutrition-related outcomes. There were no limits on study
design. Conference abstracts and registered trials were included if
published or registered within five years prior to the search.
As study screening was underway, it became clear that the sub-
question examining the prevalence of nutrition-related outcomes
in transgender individuals would need to be revised. Due to the
large amount of evidence available describing prevalence of
nutrition-related outcomes in this population, the scoping review
team specified that in order to accurately determine if transgender

Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx 5

Table 3
In individuals who are transgender, what is the availability of literature describing the prevalence of health outcomes compared to the cisgender population? N ¼ 64 studies.

Green ¼ 0 studies; Yellow ¼ 1-5 studies; Red ¼ 6-10 studies; Dark Red >10 studies.

individuals were at higher risk of a nutrition-related outcome, rates
of the outcome would need to be compared to an equivalent cis-
gender population. For individuals utilizing cross-sex hormones,
these medications could shift an individual's risk for various sex-
correlated conditions and clarity is needed to determine if these
changes surpass or exceed known risks in matched populations. In
addition, it was clarified that “prevalence” referred to diagnosable
health outcomes, such as malnutrition or cardiovascular disease
(CVD), rather than intermediate outcomes such as weight or labo-
ratory values. In order to identify studies with more power to
accurately detect prevalence, a minimum of 100 participants was
required for reported health outcomes.
The sub-question examining the nutrition-related effects of
hormone therapy in transgender individuals was also revised, as
many studies were identified. It was clarified that studies exam-
ining intermediate outcomes from hormone therapy needed to
measure before and after values of the measured outcome, and
examine a duration of at least three months of hormone therapy.
Studies reporting the effects of hormone therapy on health out-
comes needed to have followed participants for mean or median of
five years and include at least 100 participants, since smaller
studies may not be generalizable to the overall transgender
population.
2.2. Search plan
The scoping review team worked with an information specialist
to translate research objectives and eligibility criteria into a search
plan. The information specialist conducted a search of MEDLINE
(Ovid), Embase (Ovid), PsycINFO (Ebsco), CINAHL (Ebsco), Web of
Science, Cochrane Central Register of Controlled Trials (Ovid),
Cochrane Database of Systematic Reviews (Ovid), Health

Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
6 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
Table 4
Validity and reliability of nutrition assessment methods for individuals who are transgender, compared to an assessment reference standard.
Study Population Description Age Group
Grimstad et al., 2018 Transgender and Youth and
[81] gender non-binary adolescents
Retrospective Cohort (TGNB)
(abstract)
University of California, Transgender and Adolescent,
San Francisco Gender Nonbinary Adult
Practice Guideline
Technology Assessment Database (Ovid) and Database of Abstracts
of Reviews of Effects (DARE) (Ovid) databases from as well as
ClinicalTrials.gov and WHO International Clinical Trials Registry
Platform for registered trials published from January 1999 until
December 5, 2019. Animal studies were removed using a double-
not subject heading filter where appropriate. Searches were
limited to English-language only and conference abstracts were
retained in all databases. No study design or other search filters
were applied. All citations were downloaded and de-duplicated in
EndNote X8. In order to be included, articles, abstracts or trials
needed to include terminology for both transgender individuals
and for nutrition-related interventions or outcomes. The search
plan can be found in Supplement 1.
2.3. Study selection & data extraction
Results from the databases search were loaded onto Rayaan, a
title/abstract screening software [10]. Each title/abstract was
independently screened by a project manager and lead analyst. Any
title/abstract included by at least one reviewer went on to the next
stage of “full-text” review. Two individuals independently reviewed
each “full-text”, which included conference abstracts and regis-
tered trials, and discrepancies were addressed by consensus. As
described above, eligibility criteria for sub-questions 2 and 5
evolved during the study selection process.
The project manager and lead analyst extracted data onto an
excel spreadsheet. Data extracted included bibliographic informa-
tion and study design; description of transgender participants, age
group (0e9 years, 10e17 years,
18 years), hormone status (un-
clear, no hormone therapy, feminizing therapy, masculinizing
therapy, puberty blocking therapy) and sample size; study duration
(when applicable), sub-question(s) answered, details on dietary
intake, nutrition assessment method or nutrition interventions
when applicable; and outcomes reported. Data was extracted from
the full texts of peer-reviewed articles. Data was extracted directly
from the abstract when the included study was a conference ab-
stract only. Data was extracted from the registered trial websites for
registered trials when the included study was reported as a regis-
tered trial only. One reviewer extracted data and a second reviewer
verified extracted data for each included study. Data was presented
in table, heat maps and bubble charts. There was no critical
appraisal of study results or evidence quality, as is customary for
scoping reviews.
3. Results
The search of the databases identified 5403 studies including
full peer-reviewed studies and systematic reviews, conference
Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
Hormone Status Sample Size Nutrition Assessment Comparison
Method and measures
Puberty blockers (GnRH analogs) 273 Method: Growth chart Population
followed by masculinizing and 79 assigned male at (not specified) norms
feminizing gender affirming birth (AMAB) and 194 Measures:
hormone therapy (GAT) assigned female at birth ∙ Tall or short stature
(AFAB) (>or < 3SD,
respectively)
∙ Weight >97th or
<3rd %ile
Feminizing and masculinizing NA Method: Lab values Population
hormone therapy Measures: norms
∙ Liver enzymes
∙ Hb/Hct
abstracts and registered trials. Following title/abstract screening,
426 studies underwent “full-text” review and 189 were included
in qualitative analysis (Fig. 1) [3,11e198]. Of the studies included,
146 were full-text peer-reviewed studies, 33 were conference
abstracts and eight were registered trials. Participant ages were
not clear in all studies and several, particularly population-based
surveys, included multiple age groups. Children 0e9 years of age
were included in the target population in 12 studies, adolescents
10e17 years were included in 62 studies and adults were
included in 161 studies. Nearly all studies were observational in
nature, including 46 cross-sectional studies, five caseecontrol
studies and 94 cohort studies. Additionally, there were 19 non-
controlled trials, three randomized controlled trials (RCTs),
twenty scoping or systematic reviews and two evidence-based
practice guidelines. There were ten studies included that re-
ported dietary intake in transgender individuals (sub-question
1), 64 studies that reported nutrition-related health disparities
in transgender compared to cisgender individuals (sub-question
2), one study that examined the validity and reliability of nutri-
tion assessment methods (sub-question 3), two studies that re-
ported nutrition interventions (sub-question 4), and 127 studies
that reported on the intermediate and health effects of hormone
therapy (sub-question 5).
The evidence-based guidelines included discussed a range of
healthcare recommendations for healthcare practitioners working
with the transgender population. They specifically addressed the
prevalence of health outcomes as well as screening and assessment
recommendations for nutrition-related labs pertaining to hormone
therapy [3,198]. Some studies addressed multiple sub-questions.
The available literature examining nutrition related health dispar-
ities (sub-question 2) and the effects of hormone therapy on
nutrition-related intermediate outcomes (sub-question 5a)
increased over time, but the evidence examining the remaining
sub-questions has just begun to be investigated in recent years
(Fig. 2).
Sub-question 1. What is the extent, range and nature of literature
examining dietary intake in individuals who are transgender?
Ten studies examined dietary intake in transgender individuals
(Table 2); six of these were prospective cohort studies
[32,137,175,177e179,182] and four were cross-sectional studies
[42,155,165,178]. Sample sizes ranged from 21 to 989 transgender
participants, with one study including children, five studies
including adolescents, and nine studies including adults. Three
studies focused solely on quantifying the consumption of alcohol,
while three studies focused on the consumption of alcohol in
addition to intakes of other nutrients, specific food groups and/or
nutrition-related behaviors. Five studies addressed nutrition-
related behaviors such as skipping breakfast or other meals,
 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
Table 5
Included studies examining the effects of nutrition interventions in individuals who are transgender.
Study Population Description Age Group Hormone Status
Tack, Craen, Dhondt Female-to-male (FtM) Adolescents Lynestrenol (progestin) for 12.6 45
et al. 2016[161] months followed by both
Non-controlled trial lynestrenol and masculinizing
(abstract) hormones for 11.4 months
Tack, Craen, Lapauw Female-to-male (FtM) Adolescents Lynestrenol or cyproterone
et al. 2016[160] and male-to-female acetate (progestins) for mean
Non-controlled trial (MtF) duration of 11.5 months
(abstract)
eating out at fast food or other restaurants, and eating dinner with
family. Four studies addressed the consumption of specific foods
and food groups, such as fruits and vegetables and/or caloric bev-
erages (sugar-sweetened soda or fruit juice). Two studies addressed
energy intake as well as macronutrient and micronutrient intake,
while one study only examined calcium intake.
Sub-question 2. What is the extent, range and nature of literature
examining nutrition-related health disparities in individuals who
are transgender compared to individuals who are cisgender?
Sixty-four studies examining the prevalence of nutrition-related
health outcomes in transgender individuals compared to cisgender
individuals met inclusion criteria (Table 3). Studies were all
observational in nature, including 11 cohort studies [11,15,17,30,
32,51,61,74,102,120,121,141], four caseecontrol studies [117,140,192,
195], forty cross-sectional studies [11,12,18,20,21,25,26,31,
34,43e45,48e50,57,60,62,66,70,89,90,94,98,103,112,114,116,124,
128,135,144,148,155,156,165,184,185,196,197], eight scoping [39] or
systematic reviews [41,56,63,99,134,149,186], and one guideline [3].
Samples sizes in primary studies ranged from 104 to 7454 in-
dividuals from the target populations. Studies most frequently
examined prevalence of health outcomes in adults
18 years of age
(n ¼ 56), followed by studies with adolescents 10e17 years of age
(n ¼ 23) and children 0e9 years of age (n ¼ 7) as the populations of
interest (some studies included multiple age groups). Many of these
studies analyzed large, population-based data to examine trends in
health outcomes in a national sample of transgender individuals
compared to matched, cisgender controls. However, among these
studies, hormone status of transgender individuals was rarely
documented. The most frequently reported outcomes were anxiety,
depression or suicide (n ¼ 24), alcohol abuse (n ¼ 17), malnutrition,
primarily overweight and obesity prevalence (n ¼ 17), diabetes
(n ¼ 16), eating disorders (n ¼ 15), and CVD or CVD events (n ¼ 15).
There was little information on the prevalence of metabolic syn-
drome (n ¼ 1), anemia (n ¼ 1) or food insecurity (n ¼ 4).
Sub-question 3. What is the extent, range and nature of literature
examining validity and reliability of nutrition assessment methods,
compared to a reference standard, in individuals who are
transgender?
One abstract examined variations in the growth charts of
transgender and gender non-binary (TGNB) youth and adolescents,
who delayed their natal gender puberty through the use of
gonadotropin-releasing hormone (GnRH) analogs, followed by
either masculinizing or feminizing gender-affirmative hormone
therapy. Authors reported the proportion of participants who
qualified as having tall or short stature or high or low weight per-
centiles compared to growth charts describing population norms
[81]. Additionally, a 2016 practice guideline described which
gender standards to use when assessing liver enzymes and he-
moglobin or hematocrit levels in transgender individuals on hor-
mone therapy [3] (Table 4).
Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
7
Sample Size Intervention Comparison Outcomes
Reported
Vitamin D supplement Not reported Intermediate
(25,000 U/ml) and Anthropometrics
calcium enriched diet Blood Glucose
Liver Enzymes
Lipid Profile
Iron/Hgb/Hct
48 33 FtM Vitamin D Not reported Intermediate
and 15 MtF supplementation and Anthropometrics
calcium enriched diet Bone Density
Sub-question 4. What is the extent, range and nature of literature
examining the effect of nutrition interventions on nutrition-related
intermediate and long-term health outcomes in individuals who
are transgender?
Two non-controlled trials studied female-to-male (FtM) and
male-to-female (MtF) adolescents with advanced pubertal devel-
opment taking progestins rather than gonadotropin-releasing
hormone analogs [160,161]. In one trial, 45 FtM adolescents sup-
pressed their menstruation with lynestrenol for 12.6 months, fol-
lowed by both lynestrenol and masculinizing hormones for 11.4
months while also receiving vitamin D supplementation (25,000 U/
ml) and consuming a calcium-enriched diet. The effects on an-
thropometrics, blood glucose, lipid profile, liver enzymes and he-
moglobin/hematocrit were reported. In the second trial, 33 FtM
adolescents taking lynestrenol and 15 male-to-female (MtF) ado-
lescents taking cyproterone acetate for a mean duration of 11.5
months, along with vitamin D supplementation and consumption
of a calcium-enriched diet, reported effects on anthropometrics
and bone density (see Table 5).
Sub-question 5. In individuals who are transgender, what is the
availability of literature examining the effect of hormone therapies
on nutrition-related intermediate and health outcomes?
A total of 126 studies examining the effect of hormone therapies
on nutrition-related intermediate (N ¼ 119) [3,13,14,16,17,19,
22e24,27e29,33,35e38,40,46,47,52e55,58,63e65,67e69,71e73,
75,76,78,80e85,86e88,91e93,95e97,100,101,104e111,113,118,
119,122,125-127,129e133,136-139,142,143145e147,150-154,
157e159],[160e164,166e177,181e183,186-188,190,193,194,198]
and health (N ¼ 20) [3,15,27,52,59,63,77-79,81,83,115,119,134,186,
188,189,191,192,198] outcomes met inclusion criteria (Table 6).
Study designs were primarily prospective and retrospective cohort
studies, with sample sizes as large as 3100 transgender subjects.
There were three RCTs with sample sizes ranging from 30 to 53
participants and 19 non-controlled trials with sample sizes ranging
from 16 to 341 participants. Fifteen of the included studies were
systematic reviews, and there were two practice guidelines that
addressed effects of hormone therapy and, consequently, nutrition
assessment and screening methods to prevent adverse health
outcomes related to hormone therapy [3,198].
Studies were classified according to participants' hormone
therapy status (feminizing or masculinizing hormone therapy or
puberty blockers) as well as by participants’ age category. There
were 21 studies in which adolescents (aged 10e17 years) trans-
gender participants received puberty blockers, with four of those
studies conducted while participants were children (aged 0e9
years) and eight of the studies following those participants into
adulthood (
18 years of age). Thirty-one studies included adoles-
cents being treated with masculinizing and/or feminizing hormone
therapies. While most studies included both MtF and FtM adult
transgender participants, there was more research overall with
8 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx

Table 6
Included studies examining the effects of hormone therapy on nutrition-related intermediate and health outcomes in transgender individuals.

Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
Green ¼ 0 studies; Yellow ¼ 1-5 studies; Red ¼ 6-10 studies; Dark Red >10 studies.
participants treated with masculinizing hormone therapies
(N ¼ 100) compared to feminizing hormone therapies (N ¼ 85). No
studies examined nonbinary subjects exclusively.
For transgender adolescents being treated with puberty blockers,
the most frequently reported intermediate outcomes were anthro-
pometric, BMI or body composition measures (N ¼ 12) and bone
density (N ¼ 8), with fewer studies available reporting outcomes such
as laboratory values (such as blood glucose, lipid profile, liver en-
zymes, iron/hemoglobin/hematocrit) and blood pressure. There were
limited studies reporting long-term health outcomes.
For transgender adults being treated with feminizing hormone therapy, the
most frequently reported intermediate outcomes were anthropometric, BMI and
body composition measures (N ¼ 48), lipid profile (N ¼ 36) and bone density
(N ¼ 26), followed by blood glucose levels (N ¼ 16), liver enzyme levels (N ¼ 15),
blood pressure (N ¼ 15) and iron/hemoglobin/hematocrit levels (N ¼ 15). Long-
term effects of feminizing hormone therapy were most often studied for the
health outcomes of cardiovasculardisease and events (N ¼ 9), cancer (N ¼ 7) and
mortality (N ¼ 6).
For transgender adults being treated with masculinizing hor-
mone therapy, the availability of research follows a similar pattern.
The most frequently reported intermediate outcomes were
anthropometric, BMI, or body composition measures (N ¼ 62), lipid
profile (N ¼ 50), blood glucose levels (N ¼ 26), iron/hemoglobin/
hematocrit levels (N ¼ 25) and bone density (N ¼ 25), followed by
blood pressure (N ¼ 22) and liver enzyme levels (N ¼ 20). Also in line
with the long-term health effects of feminizing hormone therapies,
the long-term effects of masculinizing hormone therapies were
most often studied for the health outcomes of CVD and events
(N ¼ 10), cancer (N ¼ 7) and mortality (N ¼ 6).
4. Discussion of findings
The body of nutrition-related research on the transgender
population has advanced modestly over the past two decades, with
accelerating growth in the last five years. This increase may have
been influenced by a number of factors, such as the publication of
the 2015 U S. Transgender Survey that depicted key mental and
Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
9
physical health disparities, the publication of Healthy People 2020:
Lesbian, Gay, Bisexual, and Transgender Health goals and objec-
tives, and the designation of the transgender population as a health
disparate population for research purposes by the National In-
stitutes of Health [199e201].
Among the 187 studies included in the analysis, the vast ma-
jority were observational in nature and represented cross-
sectional, caseecontrol and cohort study methodologies. A small
portion were experimental and included both non-controlled and
randomized controlled trials. Several scoping and systematic re-
views were also included. Most studies reported data on adults and
adolescents, while few reported data on children nine years of age
and younger. A range of terms was used to describe the population
of interest, which has previously been reported as a challenge when
undertaking research in this sector, and therefore underpins the
importance of utilizing content experts to capture the breadth of
expected terminology [202].
Approximately two thirds of the included studies reported on
intermediate and health effects of hormone therapy (sub-question
5). Among studies of adults receiving feminizing or masculinizing
hormone therapies, the most frequently reported outcomes were
related to anthropometric measures, lipid profiles, and bone den-
sity; long-term effects were related to cardiovascular disease and
events, cancer, and mortality. Among studies with adolescents
receiving puberty blockers, the most frequently reported outcomes
were related to anthropometric measures and bone density, with
fewer studies reporting relevant lab values. Healthcare providers,
such as registered dietitian nutritionists, can utilize these findings
to guide practice decisions when providing nutrition care for
transgender and non-binary clients.
Approximately one third of the included studies reported on
nutrition-related health disparities between transgender and cis-
gender populations (sub-question 2). The most frequently reported
outcomes were related to mental health concerns such as anxiety,
depression, or suicide, as well as alcohol abuse, malnutrition,
overweight and obesity, diabetes, eating disorders, and cardiovas-
cular disease. These findings may inform future research aimed at
10 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
addressing known nutrition-related health disparities related to
physical and mental health outcomes for transgender individuals
across the lifespan.
A small number of studies examined dietary intake in trans-
gender individuals (sub-question 1). Of these, three focused solely
on alcohol intake. This may be due to the reported rates of sub-
stance abuse among the transgender and gender non-conforming
population [199], but generally indicates a need for more robust
research related to dietary intake, including dietary patterns,
mealtime behaviors, and micronutrient intake. As dietary intake is
a core component of nutrition assessment, a greater body of
research in this area is needed to inform clinical practice guidelines
for healthcare providers, particularly registered dietitian
nutritionists.
Very few studies reported on the validity and reliability of
nutrition assessment methods (sub-question 3) or nutrition in-
terventions (sub-question 4). Multiple nutrition assessment
methods are gendered in nature, such as growth charts for boys or
girls, gender-based predictive energy equations, or recommended
body fat percentages for men and women. This represents a rela-
tively unexamined area of translational research that may inform a
gender-affirmative approach to the nutrition care process.
4.1. Strengths and limitations
This scoping review followed a rigorous methodology using a
specialized search filter for the population of interest and was in
compliance with the PRISMA scoping review checklist [8]. In
addition, this scoping review was guided by individuals with
research, practice and personal experience in transgender nutrition
in collaboration with systematic review methodologists
(Supplement 1). This scoping review considered a wide variety of
topics important to practitioners serving transgender individuals, a
population whose unique nutrition needs are becoming increas-
ingly recognized.
An additional strength of the current review was the decision
not to include articles that pertained to the greater LGBTQ popu-
lation yet did not report results specific to the transgender sub-
population. The nature of the body of LGBTQ research is such that
the subgroups of lesbian, gay, bisexual, transgender, non-binary,
and queer individuals have often been collapsed into one cate-
gory, which has blurred the distinct health and nutrition-related
considerations for each subgroup [155]. Therefore, the authors
recognize that additional studies not represented in this review
may have included transgender participants, but the decision to
exclude such studies was based on the expressed goal of exploring
research specific to the transgender population as a whole. As a
highly diverse community, it is likely that specific nutritional needs
of subgroups may not be fully understood or clarified through this
review.
A limitation of this scoping review relates to exclusion of some
articles that described the prevalence of a health outcome in the
transgender population without any comparative reference to a
control population; in this case, a cisgender population. This
comparison allowed for a reported “higher than” or “lower than”
prevalence of a particular health outcome. We also excluded case
studies that described events during the lifespan of a transgender
patient that developed into a health issue but were not necessarily
useful in describing prevalence.
An additional important limitation is the lack of systematic data
collection of gender identities in population-based surveys [202].
For example, the National Health and Nutrition Examination Survey
(NHANES) provides population-level data on the nutrition and
health status of adults and children in the United States, and is a
robust data set for nutrition-related epidemiological studies [203].
Please cite this article as: Rozga M et al., Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping
review, Clinical Nutrition ESPEN, https://doi.org/10.1016/j.clnesp.2020.08.011
At present the survey only collects demographic data on gender
with categories of male or female. This presents an opportunity to
adopt the recommended “two-step” method for the collection of
gender identity data that queries both natal sex and gender identity
[3]. In another example, many of the studies relied on self-reported
gender identity, which may underestimate actual prevalence. It is
possible that individuals would opt not to disclose their gender
identity or do not utilize the term “transgender” to describe
themselves. Given the diversity of the boarder community, any
effort to extract data pertaining only to transgender people can be
imprecise due to the continual evolution of terms individuals use to
describe themselves and historically imprecise research methods
used to capture individuals’ self-identification.
4.2. Ongoing research
We acknowledge that additional studies have been published
since the date-specific parameters of our search. These include an
in-press publication by Bishop and colleagues examining dietary
and physical activity behaviors of adolescent transgender students
and the online publication by Kirby and Linde examining the
nutritional needs of transgender and gender non-conforming col-
lege students [204,205].
4.3. Implications for future research
Clear gaps emerged in the body of nutrition-related research on
the transgender population. While further research is likely needed
in all areas discussed, there is a relative dearth of research related to
dietary intake, validity and reliability of nutrition assessment
methods, and nutrition interventions, resulting in inherent inac-
curacies and inconsistencies in delivering the nutrition care process
to the transgender community. Future clinical practice guidelines
for the nutrition care of transgender clients should also provide
guidance for clinicians to increase confidence and competency is
using inclusive terminology, counseling skills, and more broadly
conceived gender-affirmative philosophy. Observational studies
will continue to be helpful in describing correlations and parame-
ters of prevalence, while experimental studies are needed to
examine how nutrition therapy may mitigate the known effects of
hormone therapy. Studies are also needed to evaluate the appro-
priateness and effectiveness of different nutrition interventions
such as nutrition counseling, education, and coordination of
nutrition care. Lastly, given that the transgender population is
known to have disparate access to healthcare and are subject to
discrimination within the healthcare system [199], studies that
examine access to nutrition care, such as counseling and referrals to
registered dietitian nutritionists, are also warranted.
5. Conclusion
Transgender individuals have unique nutrition needs, which
may vary according to the stage of social and medical transition.
While the potential nutrition-related health outcomes of hormone
therapy and the prevalence of nutrition-related health outcomes
compared to the cisgender population have been reported
throughout the literature, there is still a paucity of research
examining effective methods of implementing nutrition therapy for
nutrition professionals working with transgender individuals. A
greater base of primary research examining relevant nutrition
topics in transgender individuals is needed before there will be
sufficient literature to inform high-quality evidence-based clinical
nutrition practice guidelines for transgender individuals.
 M. Rozga et al. / Clinical Nutrition ESPEN xxx (xxxx) xxx
Funding
This work was supported by the Academy of Nutrition and Di-
etetics through support for a methodologist and analyst (no grant
number).
Author contributions
Mary Rozga: Conceptualization, methodology, validation,
investigation, analysis, writing original draft, writing-review &
editing, supervision, project administration; Whitney Linsen-
meyer: Conceptualization, writing original draft, writing-review &
editing; Jennifer Cantwell-Wood: Conceptualization, validation,
writing-review & editing; Vaughn Darst: Conceptualization,
writing-review & editing; Erica Gradwell: Conceptualization,
methodology, validation, investigation, analysis, writing-review &
editing.
Declaration of Competing Interest
Authors have no conflicts of interest to disclose.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.clnesp.2020.08.011.
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