Nutrition Considerations for the Transgender Population

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Nutrition and Health Considerations in the Transgender Population

Article independently reviewed by the Registered Dietitian team specializing in support for personalized virtual nutrition counseling at HealthStandNutrition.com.

Over the past several decades, vital advocacy work has increased the visibility of transgender people in society. And while important steps toward 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.

With the information and research that is available today, we’ve compiled the guide below in hopes of helping this community live their healthiest lives.

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, dangerous 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). Eating disorders, dangerous weight control strategies, and body dissatisfaction are also very common in the transgender population, particularly among transgender women (1-3).

Macronutrient Considerations

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.

If you are someone who struggles with disordered eating, there are a few settings to help take the focus off of counting calories, which can be found in this blog.

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 minimum of 1 gram per kilogram of body weight is sufficient for most 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 high cholesterol levels, increasing the risk for heart disease and stroke. An eating pattern that emphasizes whole fruits and  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 as determined on an individual basis by a Registered Dietitian and choosing heart-healthy fats, such as those found in plants and fish.

Bone Health Considerations

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 body weight per day have been shown to be overall beneficial to bone health.

Calcium and Vitamin D

The role of these two nutrients in the promotion of healthy bones is well known. While all adults should aim to meet the recommended daily allowance (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 in line 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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