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Approved:

Lindsey Smith Taillie, Thesis Advisor Anna H. Grummon, Reader

Differences in dietary patterns by sexual orientation and sex in

the US: NHANES 2011-2016

By

Carmen E. Prestemon

Senior Honors Thesis Department of Nutrition

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Abstract

Objective

To determine whether dietary intake differs by sexual orientation and sex among US adults.

Methods

We examined 24-h dietary recall data from adults (n=8,851) participating in the 2011-2016 National Health and Nutrition Survey (NHANES). We compared daily caloric intake from specific food groups and Healthy Eating Index scores for sexual orientation groups (heterosexual vs. GLB [gay/lesbian/bisexual]), stratified by sex and adjusted for demographic characteristics and survey wave.

Results

Among males, red and processed meat/poultry/seafood (p=0.01) and sandwiches (p=0.02) were smaller contributors to caloric intake for gay/bisexual males compared to heterosexual males. Among females, cereals (p=0.04) and mixed dishes (p=0.02) were smaller contributors to caloric intake for lesbian/bisexual females compared to heterosexual females. Gay/bisexual males had significantly higher total HEI scores than heterosexual males (53.40 (1.36) vs. 49.29 (0.32), difference=4.14, p=0.004). Lesbian/bisexual females did not differ in total or component HEI scores from heterosexual females.

Conclusions

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Introduction

Poor dietary quality is a leading cause of disability and death in the U.S. and globally.1 Average

dietary quality remains low across U.S. adults,2 increasing risk of non-communicable diseases

including obesity, diabetes, and cardiovascular disease.3 While overall dietary quality is low,

there also remain persistent disparities in diet-related diseases by sexual orientation.4 For

example, lesbian, and bisexual females have a higher risk of being overweight and obese than heterosexual females,5,6 while GLB males have lower BMI compared to heterosexual males.7

Gay and bisexual males are also at higher risk for a number of diet-related diseases compared to heterosexual males, including showing increased risk for diabetes, high blood pressure, high cholesterol, and cardiovascular disease.6 Lesbian and bisexual females also have higher

cardiovascular disease risk compared to heterosexual females, due in part to greater alcohol consumption, illicit drug and tobacco use, poor mental health, and higher BMI.8

While persistent disparities in diet-related disease have been noted, limited research has characterized in detail how diet quality differs between gay, lesbian, and bisexual (GLB) and heterosexual individuals. Existing research has examined intake of only a few specific nutrients or food groups, such as calories, fruits and vegetables, desserts, and SSBs,7 but these categories

do not capture overall dietary quality. Additionally, these are not the only food groups associated with obesity and other diet-related disease. Other food groups include red meats, refined grains, and fast food.9 Researchers and practitioners need a more detailed understanding of differences

in dietary patterns by sexual orientation, including understanding consumption of other nutrients and food groups and of overall dietary quality. Studying the relative contribution of food groups to total calories is necessary to understand eating patterns. Eating patterns allow researchers to understand and predict health status and disease risk better than individual foods and nutrients.10

This information will elucidate whether dietary behaviors of sexual minority and heterosexual individuals differ in ways that are meaningful for non-communicable disease risk. Understanding these relationships could help develop targeted interventions to reduce health disparities between and within GLB and heterosexual populations.

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we examined consumption of nutrients, food groups, and overall dietary quality (reflected by the Healthy Eating Index) among gay, lesbian, bisexual, and heterosexual adults participating in National Health and Nutrition Examination Survey (NHANES).

Methods

Participants

We used data from the National Health and Nutrition Examination Survey (NHANES), a cross-sectional survey providing a nationally representative sample of civilian, non-institutionalized individuals that live in the United States. NHANES is continuous, multistage probability survey that includes at-home health interviews and objective health measurements collected in a mobile examination center (MEC).11 It is the most comprehensive nationally-representative dataset for

assessing dietary intake and anthropometrics. Data are collected and released in two-year cycles. We used data from the 2011-2012, 2013-2014, and 2015-2016 cycles.12, and we included

individuals ages 20-65 with complete information on dietary intake, sexual orientation, and sex (n=8,851)†.

Measures

Sexual Orientation

We categorized participants based on NHANES’ variables (Supplemental Images 1-5) for self-reported gender (male or female)‡ and sexual orientation (gay, bisexual, or heterosexual).

Participants were excluded if they selected “something else”, “not sure”, or “don’t know” for sexual orientation. Preliminary analyses comparing dietary variables between gay vs. bisexual males and lesbian vs. bisexual females revealed few differences (out of 110 comparisons, only six were statistically significant at p < 0.05). Due to few dietary differences between these two groups, and to increase sample size within groups, we combined gay and bisexual groups for analyses. Thus, we categorized participants as: heterosexual males (n=4,230), gay and bisexual males (n=173), heterosexual females (n=4,165), and lesbian and bisexual females (n=283).

No adults had missing data on dietary intake or sex. Missingness of sexual orientation was 64.94%.

While NHANES uses male and female to describe gender, these terms are typically used to describe biological sex.

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Food and Beverage Intake

We examined total daily dietary intake using 24-hour dietary recall data and, for fast food and pizza consumption, food frequency items. We limited dietary recall data to the first day,

consistent with National Cancer Institute recommendations for estimating mean usual intake in a population.15

Analyses examined consumption of 20 food and beverage groups, as shown in Table 2.16,17

Within these groups, we calculated adjusted mean daily calorie intake and mean percent contribution to total daily calorie intake. Using the mean percent contribution to total daily calorie intake, we also looked at the top five caloric contributors for each food and beverage group. For the fast food and pizza group, we calculated adjusted mean meals per week.

Healthy Eating Index

To provide an overall assessment of dietary quality, we also examined participants’ Healthy Eating Index (HEI) scores. HEI component scores and total scores are calculated based on whether an individual meets standards established by the Dietary Guidelines for Americans. The components are total fruits, whole fruits, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, refined grains, added sugars, fatty acids, sodium, saturated fats, and energy. Higher scores indicate better diet quality, with a maximum of 100 for the total score.18 We calculated HEI scores by applying the National Cancer Institute HEI scoring

macro to the first day of the 24-hour dietary recall data.19

Covariates

Covariates included age (20-29 years, 30-39 years, 40-54 years, and 55-65 years), race/ethnicity (Mexican American, Other Hispanic, non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Other race/multiracial), education level (<9th grade, 9th-11th grade, High school

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Statistical Analyses

First, we calculated proportions or means and standard deviations of covariates and body mass index (BMI, kg/m2) for each sexual orientation group. Next, we used ordinary least squares

regression to calculate adjusted means for each outcome, as well as adjusted differences in means across groups, controlling for covariates (e.g., age, race/ethnicity). Descriptive statistics and food group measures were computed in Stata/SE 15 and HEI scores were calculated using SAS 9.4 (SAS Institute, Cary, NC). Missingness on most variables was 2% or less (see Table 1), so analyses used complete case analysis. All analyses used a two-tailed alpha level of 0.05 and adjusted for NHANES complex survey design.

Results

The sample population was predominantly white, born in the U.S., and covered by health

insurance (Table 1). Among males, gay and bisexual males were slightly more educated, slightly less wealthy, and smoked more compared to heterosexual males. The depression score for gay and bisexual males was higher than for heterosexual males (4.4 ± 3.5 for gay and bisexual males and 2.7 ± 3.3 for heterosexual males). Both groups consumed a similar amount of alcohol. Gay and bisexual males had a lower average BMI (27.3 ± 5.0 for gay and bisexual males vs. 28.9 ± 5.2 for heterosexual males). Among females, the lesbian and bisexual sample was much younger, had a larger proportion of individuals below 185% of the federal poverty line, and had a higher smoking prevalence compared to heterosexual females. When compared to heterosexual females, lesbian and bisexual females also had a higher average depression screener score (5.5 ± 4.5 vs. 3.5 ± 3.8) and higher BMI (30.4 ± 7.1 vs. 29.3 ± 6.6).

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Among females, lesbian and bisexual females consumed more total calories (difference = 105 calories/day, p=0.12), fewer calories from mixed dishes (difference= -50 calories/day, p=0.07), and more calories from hamburgers and pizza (difference= 43 calories/day, p=0.15) than heterosexual females.

While absolute intakes did not differ across sexual orientation groups, there were some differences by sexual orientation in the relative contribution of the food/beverage categories studied (Table 3). Red and processed meat/poultry/seafood was a smaller contributor to total caloric intake for gay and bisexual males than heterosexual males (difference= -2.2%, p=0.01), as were sandwiches (difference= -1.4%, p=0.02). Breakfast cereals (difference= -0.8%, p=0.04) and mixed dishes (difference= -3.4%, p=0.02) were a smaller contributor to total caloric intake among lesbian and bisexual females than heterosexual females.

Sexual orientation groups were relatively similar in the top five contributors to total caloric intake (Table 4). For all sex and sexual orientation groups, mixed dishes contributed the most to daily intake, followed by desserts and sweet snacks. Breads and grains were a top contributor for all groups except for gay and bisexual males. Gay and bisexual males were the only group to have beverages as top contributors (SSBs at 6.7% and alcohol at 6.4%). Both heterosexual males and gay and bisexual males had hamburgers and pizza as top contributors, and both heterosexual females and lesbian and bisexual females had salty snacks as a top contributor.

Gay and bisexual males had significantly higher HEI scores than heterosexual males (53.40 vs. 49.26; difference=4.14, p=0.004) (Figure 1, Supplemental Table 1). Gay and bisexual males also had higher scores for fatty acids (difference=1.01 points, p=0.02) and sodium

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Table 1. Demographic characteristics by sex and sexual orientation, NHANES 2011-2016

Males Females

Characteristics

Heterosexual Gay and Bisexual

Heterosexual Lesbian and Bisexual

n=4,230 n=173 n=4,165 n=283 % or Mean (N) or (SD) % or Mean (N) or (SD) % or Mean (N) or (SD) % or Mean (N) or (SD) Age

20-29 years 27.1% 1131 33.6% 65 23.8% 1024 47.4% 130

30-39 years 24.3% 1131 16.3% 33 21.9% 1000 24.8% 75

40-54 years 35.5% 1504 31.3% 53 39.9% 1659 22.1% 63

55-65 years 13.1% 464 18.8% 22 14.4% 482 5.6% 15

Mean (SD) 39.1 10.0 39.6 10.0 40.5 10.0 32.9 9.1

Race/Ethnicity

Mexican American 10.7% 593 3.6% 14 9.5% 577 6.4% 23

Other Hispanic 6.4% 389 5.7% 13 6.6% 454 5.7% 24

Non-Hispanic White 62.6% 1621 75.4% 84 63.1% 1557 63.4% 117

Non-Hispanic Black 11.2% 916 8.4% 35 12.7% 995 14.7% 80

Non-Hispanic Asian 5.3% 529 4.4% 20 5.1% 437 3.8% 17

Other race including

multi-racial 3.7% 182 2.5% 7 2.9% 145 6.0% 22

Education level

<9th grade 3.4% 207 0.8% 3 2.9% 173 1.9% 7

9th-11th grade 11.2% 603 3.4% 11 7.9% 441 10.3% 35

High school diploma/GED 23.0% 1011 21.1% 40 17.7% 775 23.3% 69

Some college/associates

degree 32.4% 1285 40.7% 65 35.8% 1502 39.7% 113

College graduate or higher 30.0% 1124 34.0% 54 35.8% 1274 24.9% 59

Nativity

US born 81.8% 3005 89.9% 138 83.5% 3019 90.2% 244

Foreign born 18.2% 1222 10.1% 35 16.5% 1145 9.8% 39

Income to poverty ratio

Below 185% 31.5% 1749 32.8% 68 32.0% 1743 50.6% 155

185%-300% 16.4% 664 19.5% 40 16.6% 674 12.1% 35

>300% 46.5% 1521 39.5% 57 46.1% 1480 33.7% 78

Current cigarette smoker

Yes 24.2% 1151 28.6% 54 19.1% 766 41.3% 107

No 75.8% 3078 71.4% 118 80.9% 3397 58.7% 176

Health insurance coverage

Yes 75.8% 2951 84.0% 130 82.3% 3256 75.9% 199

No 24.1% 1277 16.0% 43 17.6% 904 24.1% 84

Depression, mean (SD) 2.7 3.3 4.4 3.5 3.5 3.8 5.5 4.5 Alcoholic drinks/day past 12

mo., mean (SD) 0.9 1.3 0.9 1.2 0.4 0.7 0.5 0.9

BMI, mean (SD) 28.9 5.2 27.3 5 29.3 6.6 30.4 7.1

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Table 2. Daily caloric intake of energy, foods, and beverages by sex and sexual orientation, NHANES 2011-2016.

Males Females

Heterosexual

(n=4,230) Gay and Bisexual(n=173) Difference Heterosexual(n=4,165) Lesbian and Bisexual(n=283) Difference

Adjusted

Mean SE AdjustedMean SE Diff. p Adjusted Mean SE Adjusted Mean SE Diff. p

Total Energy Intake

(kcals) 2609 22 2672 106 63 0.58 1926 15 2031 67 105 0.12

Foods

Breads and grains 175 6 160 18 -16 0.40 126 5 130 12 4 0.74

Breakfast cereals 56 3 78 18 22 0.25 50 3 37 8 -13 0.17

Cheese and yogurt 71 4 70 15 -2 0.91 60 3 60 9 0 0.99

Desserts and sweet

snacks 272 9 289 52 17 0.75 223 7 249 25 27 0.28

Fruits 51 2 64 9 13 0.20 49 2 54 6 5 0.43

Nuts, legumes, and other non-meat proteins

140 7 164 20 24 0.21 107 5 113 17 6 0.75

Red and processed

meat/poultry/seafood 159 7 116 20 -42 0.06 86 4 96 13 10 0.45

Lean and unprocessed

meat/poultry/seafood 155 8 177 33 22 0.51 107 5 104 16 -3 0.86

Mixed dishes 475 14 408 47 -67 0.17 361 10 311 27 -50 0.07

Salty snacks 163 5 152 22 -11 0.65 129 5 143 18 14 0.45

Sauces/dips/condiments 76 3 118 24 42 0.09 68 3 80 12 11 0.35

Vegetables 32 2 40 7 8 0.33 33 1 38 6 5 0.37

Hamburgers and pizza 182 11 170 40 -11 0.78 92 6 135 30 43 0.15

Sandwiches 77 6 46 15 -32 0.06 53 4 43 12 -10 0.40

Beverages

100% Juice 35 5 26 7 -8 0.14 22 2 23 9 2 0.86

Alcohol 138 6 195 34 58 0.08 120 6 144 18 25 0.20

Milk and other dairy 69 4 66 16 -3 0.84 40 3 35 10 -5 0.61

SSBs 164 7 174 25 10 0.68 100 4 116 15 16 0.26

Other beverages 23 3 40 17 17 0.33 23 3 37 10 14 0.18

Food away from home (meals/week)

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Table 3. Percent daily intake of energy, foods, and beverages by sex and sexual orientation, NHANES 2011-2016.

Males Females

Heterosexual

(n=4,230)

Gay and Bisexual

(n=173)

Difference Heterosexual(n=4,165) Lesbian and Bisexual(n=283) Difference

Adjusted

Mean % SE

Adjusted

Mean % SE Diff. p

Adjusted

Mean % SE

Adjusted

Mean % SE Diff. p

Foods

Breads and grains 7.1 0.2 6.2 0.7 -0.8 0.28 6.8 0.3 7.1 0.7 0.2 0.71

Breakfast cereals 2.3 0.1 2.9 0.7 0.6 0.43 2.7 0.2 1.8 0.3 -0.8 0.04

Cheese and yogurt 2.8 0.1 2.6 0.5 -0.2 0.70 3.4 0.2 3.1 0.4 -0.3 0.44

Desserts and sweet snacks 9.7 0.3 10.2 1.6 0.4 0.80 11.1 0.3 11.4 0.9 0.3 0.75

Fruits 2.2 0.1 2.8 0.5 0.6 0.25 2.9 0.1 3.0 0.4 0.1 0.75

Nuts, legumes, and other

non-meat proteins 5.2 0.2 6.3 0.8 1.1 0.21 5.6 0.3 5.3 0.7 -0.3 0.72

Red and processed

meat/poultry/seafood 6.3 0.3 4.1 0.7 -2.2 0.01 4.6 0.2 5.0 0.7 0.4 0.53 Lean and unprocessed

meat/poultry/seafood 6.2 0.3 6.8 1.1 0.6 0.62 5.7 0.3 5.6 0.8 -0.1 0.92

Mixed dishes 18.4 0.5 15.9 2.0 -2.5 0.23 18.5 0.5 15.0 1.4 -3.4 0.02

Salty snacks 6.3 0.2 5.4 0.8 -0.9 0.30 6.6 0.2 6.7 0.8 0.0 0.97

Sauces/dips/condiments 2.9 0.1 4.8 1.2 1.9 0.11 3.6 0.1 3.7 0.6 0.1 0.85

Vegetables 1.5 0.1 1.5 0.3 0.1 0.84 1.9 0.1 2.1 0.3 0.2 0.58

Hamburgers and pizza 6.4 0.4 6.2 1.5 -0.2 0.90 4.6 0.3 7.4 1.6 2.8 0.07

Sandwiches 3.0 0.2 1.6 0.5 -1.4 0.02 2.7 0.2 1.8 0.5 -0.9 0.07

Beverages

100% Juice 1.3 0.1 1.3 0.5 -0.01 0.99 1.1 0.1 1.2 0.4 0.1 0.73

Alcohol 5.0 0.2 6.4 0.9 1.5 0.11 5.4 0.2 6.6 0.8 1.2 0.17

Milk and other dairy 2.6 0.2 2.3 0.6 -0.3 0.62 2.1 0.1 1.6 0.4 -0.5 0.20

SSBs 6.3 0.3 6.7 0.8 0.4 0.65 5.2 0.2 5.6 0.6 0.3 0.56

Other beverages 0.9 0.1 1.4 0.6 0.5 0.40 1.2 0.1 1.6 0.4 0.4 0.40

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Table 4. Top contributors to total caloric intake by sex and sexual orientation, NHANES 2011-2016

Males Females

Top calorie contributors

Heterosexual

(n=4,230)

Gay and Bisexual

(n=173)

Heterosexual

(n=4,165)

Lesbian and Bisexual

(n=283)

Food Group Percent Food Group Percent Food Group Percent Food Group Percent

1st Mixed dishes 18.4 Mixed dishes 15.9 Mixed dishes 18.5 Mixed dishes 15.0

2nd Desserts and sweet

snacks 9.7

Desserts and sweet

snacks 10.2

Desserts and sweet

snacks 11.1

Desserts and sweet

snacks 11.4

3rd Bread and grains 7.1 Lean and unprocessed

meat/poultry/seafood 6.8 Bread and grains 6.8 Hamburgers and Pizza 7.4

4th Hamburgers and pizza 6.4 SSBs 6.7 Salty snacks 6.6 Breads and grains 7.1

5th Red and processed

meat/poultry/seafood 6.3 Alcohol 6.4

Lean and unprocessed

meat/poultry/seafood

5.7 Salty snacks 6.7

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Figure 1. Adjusted differences in Healthy Eating Index-2015 (HEI) scores, GLB vs. heterosexual, NHANES 2011-2016.

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Discussion

Our analyses revealed differences in dietary quality for gay and bisexual males compared to heterosexual males, but few differences between lesbian and bisexual females and heterosexual females. While the absolute intakes are similar for gay and bisexual versus heterosexual males, relative contributions of food groups and qualitative measures from the HEI differed between sexual orientation groups. Specifically, gay and bisexual males had higher total HEI, FA, refined grains, and sodium scores than heterosexual males. A higher total HEI score and higher

component scores indicate better alignment with the Dietary Guidelines for Americans,20 and

therefore a more “nutritionally adequate diet,”10 suggesting gay and bisexual males had

somewhat better overall dietary quality (and therefore, lower risk of diet-related disease) than heterosexual males. In addition, gay and bisexual males had lower red and processed

meat/poultry/seafood percent intake and higher lean and unprocessed meat/poultry/seafood percent intake compared to heterosexual males. These differences are also indicative of better diet quality and lower diet-related disease risk, as consumption of more lean and unprocessed meats and less red and unprocessed meats have been linked to healthier weight and reduced risk of chronic diseases, including cancer.10 While gay and bisexual males had higher total HEI

scores than heterosexual males, we found few statistically-significant differences between these groups in consumption of most other food groups, including sugar-sweetened beverages, fruits, vegetables, and desserts and sweet snacks, suggesting room for improvement for all groups. However, we did find differences in relative contribution of red and processed meats and sandwiches, which could be driving this difference in total HEI scores among males.

The observed dietary quality differences between gay and bisexual and heterosexual males could be due to a variety of social factors related to eating. For example, gay and bisexual males experience more frequent dieting behaviors and are at a higher risk for developing an eating disorder compared to their heterosexual counterparts. Additionally, gay men are more likely to experience body dissatisfaction and a drive for thinness and muscularity compared to

heterosexual males.21, 22, 23 More research will clarify the pathways through which sexual

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While we observed some differences between heterosexual and lesbian and bisexual females, these differences did not paint a consistent picture about which group had better dietary quality. While lesbian and bisexual females have a smaller, statistically significant relative contribution of breakfast cereals and mixed dishes, these categories do not clearly indicate a healthier or unhealthier diet compared to heterosexual females. Breakfast cereals do not clearly indicate diet quality, since they can vary widely in their whole grain and sugar content. Mixed dishes do not clearly indicate, because they include a combination of processed and unprocessed meats, as well as whole and refined grains. Overall, there were not major differences between groups. Few studies have analyzed dietary intake and sexual orientation among women.24,25,26 One study used

HEI to compare the diet between lesbian and bisexual women and heterosexual women, and found that heterosexual women had a lower HEI.24 In contrast, we did not observe different HEI

scores for lesbian and bisexual compared to heterosexual females. Two other studies compared fruit and vegetable consumption between heterosexual and lesbian/bisexual females, but did not assess HEI. One found that fruit and vegetable consumption did not differ25, while another found

that lesbian and bisexual females consume less fruits and vegetables than heterosexual females.26

In contrast, we did not observe differences in fruit and vegetable consumption. Our findings likely differ, because the dietary data collected by the California Health Interview Survey (CHIS) is not as detailed and comprehensive as the dietary data collected by NHANES. The CHIS only collects information about fruit, vegetable, potato, legume, soda, fruit juice (100% and

sweetened), and dessert intake, while NHANES conducts a complete dietary recall.

While some differences were observed across groups, diet quality was poor for all groups, as demonstrated by the low total HEI scores. Furthermore, all groups had low scores for whole grains, and higher whole grain consumption is associated with lower body weight.10 Further

researcher is needed to understand the dietary difference between heterosexual males and gay and bisexual males, as well as understand the low scores across all components and groups, particularly among the fruit, vegetable, processed meat, and whole grain categories.

Strengths and Limitations

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collected via self-report, and it is possible that different sexual orientation groups reported intake differentially. For example, underreporting of intake is more likely among overweight/obese individuals.27 Given that overweight/obesity prevalence is higher among lesbian and bisexual

females, it is possible that there was also differential underreporting of diet or key dietary components for lesbian and bisexual females, and it is unclear in which direction this potential bias would affect our results. Additionally, there may have been issues relating to how sexual orientation was reported. NHANES gives the following options for sexual orientation:

heterosexual or straight, homosexual or gay/lesbian, bisexual, something else, and not sure. This does not account for other sexual orientations, such as pansexual or asexual. Additionally, the only options for gender were male or female, precluding examination of transgender, non-binary, genderqueer, or any other gender identities. A large portion of the sample had missing

information for sexual orientation (missingness = 64.95%). It is possible that people who did not report sexual orientation are more likely to be GLB or another sexual orientation.28 These

individuals may have differential diet quality, but it is not clear on how these would influence the observed associations. In addition, the sample size was small for GLBs, so we had to combine gay/lesbian and bisexual into one group, preventing us from analyzing potential differences between gay/lesbian individuals and bisexual individuals. Smaller sample sizes of GLB

individuals may have also contributed to the lack of statistically significant differences between groups for some outcomes that showed relatively large absolute differences. Future studies should oversample LGBTQ+ individuals to provide a more detailed picture of dietary intake for these groups. More research will clarify how dietary patterns may differ across sexual minorities, and how dietary differences may interact with other social factors to influence disease risk.

Conclusions

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Supplemental Material

Supplemental Table 1. Healthy Eating Index-2015 (HEI) by sex and sexual orientation, NHANES 2011-2016

Males Females

Heterosexual Gay and Bisexual

Difference Heterosexual Lesbian and Bisexual Difference

n=4,230 n=173 n=4,165 n=283

Variable Adjusted

Mean SE AdjustedMean SE Diff. p-value AdjustedMean SE AdjustedMean SE Diff. p-value

Health Eating Index Score -

2015 49.26 0.32 53.40 1.36 4.14 0.004 51.59 0.37 51.88 1.03 0.29 0.79

Adequacy

Total vegetables 2.88 0.05 3.05 0.19 0.17 0.41 3.11 0.04 3.07 0.15 -0.04 0.79 Greens and beans 1.46 0.06 1.80 0.23 0.33 0.19 1.71 0.06 1.65 0.15 -0.07 0.68

Total fruit 1.72 0.05 1.87 0.21 0.15 0.49 1.96 0.05 2.11 0.17 0.15 0.39

Whole fruit 1.70 0.05 2.02 0.19 0.31 0.11 2.02 0.06 2.04 0.18 0.03 0.89

Whole grains 2.28 0.08 2.43 0.37 0.15 0.70 2.61 0.09 2.63 0.25 0.02 0.95

Dairy 5.04 0.09 4.54 0.35 -0.50 0.17 5.08 0.09 4.91 0.34 -0.17 0.63

Total protein foods 4.32 0.03 4.20 0.20 -0.11 0.56 4.13 0.04 4.01 0.13 -0.13 0.39 Seafood and plant

proteins 2.25 0.06 2.68 0.23 0.43 0.08 2.36 0.07 2.48 0.18 0.12 0.52

Fatty acids 4.90 0.09 5.91 0.41 1.01 0.02 5.22 0.11 5.33 0.30 0.10 0.74

Moderation

Sodium 4.14 0.07 5.14 0.37 1.01 0.01 4.33 0.10 4.53 0.27 0.21 0.47

Refined grains 6.23 0.09 7.02 0.44 0.79 0.08 6.31 0.10 6.63 0.32 0.32 0.32

Saturated fat 5.81 0.09 6.41 0.42 0.60 0.17 6.10 0.08 6.23 0.27 0.13 0.63

Added sugar 6.53 0.09 6.33 0.31 -0.19 0.50 6.64 0.07 6.26 0.31 -0.38 0.24

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Supplemental Image 1. NHANES Gender Question, 2015-2016

Note. Question is the same for NHANES 2013-2014 and 2015-2016. Information collected during screening.

Supplemental Image 2. NHANES Sexual Orientation (Male), 2011-2012

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Supplemental Image 3. NHANES Sexual Orientation (Female), 2011-2012

Note. Question is the same for NHANES 2013-2014.

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Figure

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References

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