Nutrition Considerations for the Transgender Population

Over the past several decades, vital advocacy work has increased the visibility of
transgender people in society. And while important steps towards more inclusive
healthcare have been taken, nutrition guidelines for transgender people do not
exist. However, there are several dietary implications that transgender people
should consider during and following their transition period, specifically if
masculinizing or feminizing hormone therapy is used.

Nutrition and Health Considerations in the Transgender Population

Transgender Men (Female to Male; FtM)
Testosterone (T) therapy can result in weight gain and changes to body composition
(increased lean mass and decreased body fat). In addition, while bone mass may
increase temporarily, long-term T therapy can result in accelerated bone loss.
Dyslipidemia (elevated LDL-cholesterol and low HDL-cholesterol) is also common
with T therapy and there is an increased risk for health conditions such as heart
disease, hypertension, and type 2 diabetes, when other factors (age, race, lifestyle
habits, etc.) are taken into consideration. Eating disorders, unhealthy weight control
strategies, and body dissatisfaction are also very common in the transgender
population, particularly among transgender women (1-3).
Transgender Women (Male to Female; MtF)
Similar nutrition and health-related issues may occur in transgender women
receiving hormone therapy. Dyslipidemia and changes to blood pressure can
increase the risk for blood clotting disorders, hypertension, and type 2 diabetes if
additional risk factors are present. However, in contrast to transgender men,
transgender women often have improved bone mineral density, especially if gender
reassignment surgery has occurred (1-3).

Nutrition Guidelines for the Transgender Population Energy

Energy
Popular equations used to estimate energy requirements, such as Harris Benedict or
Mifflin St. Jeor, are gendered and may not accurately capture the body composition
of transgender people. A preferable method of determining energy need is indirect
calorimetry, which uses a machine to measure oxygen consumption and carbon
dioxide production to predict energy requirements. However, indirect calorimetry
can be costly and unavailable, leaving equations as the only option for energy
assessment. If an equation is used to determine energy need, it’s advisable to
monitor weight status weekly.
For transgender people who struggle with disordered eating, eating disorders, or
poor body image, calorie counting should be avoided, with greater emphasis placed
on lifestyle habits. Calorie counting can be disabled in your Cronometer account by
unchecking “visible” next to energy under settings.
Protein
No specific protein recommendations exist for transgender people, although a
slightly higher protein intake may be beneficial in the context of weight gain. A
target of 1 g per kg of healthy body weight (i.e. weight that places BMI between
18.5 and 24.9 kg/msq) is sufficient for most healthy adults. However, factors such
as activity level and the presence of disease can influence protein requirements. For
individualized recommendations, it’s best to work with a Registered Dietitian
familiar with transgender nutrition needs (you can find a skilled professional by
searching Cronometer’s professional directory).
Fat
 Transgender individuals receiving hormone therapy may develop unhealthy
cholesterol levels, increasing the risk for heart disease and stroke. A general healthy
eating pattern that emphasizes unprocessed fruits, vegetables, whole grains,
pulses, nuts, and seeds, with reduced intakes of high fat animal products, is ideal
for improving cholesterol levels. In addition, it’s important to ensure that you are
meeting minimum fibre requirements for age and gender and choosing heart-
healthy fats, such as those found in plants and fish.

Bone Health

While bone health tends to improve for transgender women (MtF), it typically
worsens for transgender men (FtM) due to the hormonal impacts of testosterone.
Important nutrients essential for achieving optimal bone health are discussed below.
Protein
Debate exists regarding the ideal amount of protein for bone health since high
protein diets are associated with increased urinary losses of calcium (4). However,
urinary calcium losses do not necessarily lead to a negative calcium balance or
reduced bone mass (5), and moderate protein intakes of 1.0 to 1.5 g per kg (of
healthy body weight per day) have been shown to be overall beneficial to bone
health (6).
Calcium and Vitamin D
The role of these two nutrients in the promotion of healthy bones is well known.
While all healthy adults should aim to meet the RDA for calcium and vitamin D,
transgender men (FtM) receiving T therapy may benefit from an intake slightly
above the RDA to prevent osteoporosis.
Related Bone Health Nutrients:
magnesium, phosphorus, vitamin A, potassium,
zinc, vitamin B12, vitamin C, vitamin K
Bone is a complex, living tissue that requires adequate intake of many different
nutrients. However, since several of the recommended intakes for these nutrients
are gendered, it’s challenging to provide guidance on ideal targets. That said, given
the increased risk of poor bone health in transgender men (FtM), a conservative
approach is to aim for the higher intake of the two gendered options for each
nutrient, being mindful not to exceed the upper limit.
Bone Breakers
caffeine, alcohol, sodium
When it comes to preserving bone health, it’s also important to pay attention to the
foods and nutrients that interfere with the bone-building process and/or contribute
to increased calcium losses. Caffeine intake in excess of 400 mg (equivalent to four
8 oz. brewed coffees) can increase calcium loss, while excessive alcohol intake
interferes with bone-building activity. High dietary sodium can also reduce bone
density so keep daily intake to less than 2300 mg per day (7).
Iron

One other nutrient worth mentioning for its relevance to the transgender population is iron. Transgender men (FtM) receiving hormone therapy will no longer experience menstruation and as a result, iron needs are in0line with cisgender males at 8 mg per day.

Conclusion

Although significant progress has been made in medicine to enhance the lives of
transgender people, the nutritional needs of this population remain largely
unknown. Weight gain, metabolic disease, and disordered eating may all be
experienced at a higher rate in the transgender population compared to cisgenders,
which speaks to the urgent need for inclusive, evidence-based guidelines. When it
comes to choosing a sex in your Cronometer account, it may be preferable to select
the gender that has been transitioned to in order to capture the fat/muscle
composition changes that accompany hormone therapy. Careful attention should be
paid to the bone-building nutrients (for transgender men) and regular weight and
health monitoring by a medical team is important to confirm the suitability of
nutrition targets.

References:

1.
Rahman R, Linsenmeyer WR. Caring for Transgender Patients and Clients:
Nutrition-Related Clinical and Psychosocial Considerations. J Acad Nutr Diet. 2019
May;119(5):727-732. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/29779913
2.
Fergusson P, Greenspan N, Maitland L, Huberdeau R. Towards Providing Culturally
Aware Nutritional Care for Transgender People: Key Issues and Considerations.
Can J Diet Pract Res. 2018 Jun 1;79(2):74-79. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/29543495
3.
Breeding Z. Nutrition Considerations for the Transgender Community. Food &
Nutrition. 2017 Dec. Available from:
https://foodandnutrition.org/from-the-
magazine/nutrition-considerations-transgender-community/
4.
Heaney RP, Layman DK. Amount and type of protein influences bone health. Am
J Clin Nutr. 2008 May;87(5):1567S-1570S. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/18469289
5.
Bonjour JP. Dietary protein: an essential nutrient for bone health. J Am Coll Nutr.
2005 Dec;24(6 Suppl):526S-36S. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/16373952
6.
Kerstetter JE, O’Brien KO, Insogna KL. Dietary protein, calcium metabolism, and
skeletal homeostasis revisited. Am J Clin Nutr. 2003 Sep;78(3 Suppl):584S-592S.
Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/12936953
7.
Dietitians of Canada, Practice-based Evidence in Nutrition. Eating Guidelines to
Prevent Osteoporosis: It’s Never Too Late! 2018 Oct. Available through
subscription.

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