Reviewer’s report
Title: 
The Association Between Sexual Orientation, BMI, Obesity Diagnosis,
and Provider Recommendation for Weight Management
Version: 
0 
Date: 
13 Jul 2021
Reviewer: 
Filippo Alberto Ferrari
Reviewer's report:
Dear Respectable Editor,
I am grateful to give me the opportunity to review the manuscript entitled "The
Association Between Sexual Orientation, BMI, Obesity Diagnosis, and Provider
Recommendation for Weight Management".
This work from Wolfgang et al addresses a topic of great clinical interest because
growing incidence of obesity and its 
burden on public health. Obesity is a
significant public health issue and about 40% of American adults were obese in
2016. In literature some studies reported an heightened risk of obesity in sexual
minorities, including lesbian and bisexual groups, compared to straight ones.
Studies suggest that differences may be related to variance in social, behavioral,
and cultural norms by sexual minorities orientation groups. I appreciated the
novelty given to scientific literature for a such hot but under-studied topic in
women health. Furthermore, the paper had the merit to investigate how patient
sexual orientation influence providers during weight management counseling.
Nonetheless, some reflections are needed. 
Introduction is clear and adequate for the purpose. I advice to report in methods
section if weight and height used for body mass index calculation were measured
by providers or not. BMI calculated on self-reported information provided by
patients may be subject to inaccuracy and distortion. 
Different coviariates were reported in literature to be related to obesity. The
Authors collected data about race, ethnicity, marital status, provider type and
comorbidities, nonetheless surprisingly they didn't mentioned educational level
and household income and fail to provide a complete description of
demographics features of considered groups. These social and economic aspect
deeply influence the incidence of obesity (I suggest to consider this paper,
DOI:10.15585/mmwr.mm6706a3).
Inclusion criteria considered age 18-89 and, as reported in Table 1, the mean age
was more than 50 years old in lesbian and straight control groups. In my opinion,
a stratification by hormone status should be made Menopause is usually a cause
of many concerns and the incidence of obesity in the United States among
women between 40 and 65 years is calculated as 65%, and among women over
the age of 65 as almost 74%. Evidence in literature reported a three times more
often incidence of obesity and metabolic syndrome in women in this period than
before menopause. I suggest to analyze the proportion of patients with BMI >30
in different age groups. Moreover parity was another unreported aspect. Authors
should report in Limitations section if these data were not available and consider
the impact, respectively, of hypoestrogenemia and previous pregnancies on body
mass index and fat distribution in order to deeply analyze the impact on
correlated comorbidities. Furthermore the lack of an age subgroup analysis did
not allow to understand if differences between straight group and others sexual
minorities could increase or contrary reduce with age. I advice to consider this
publication: doi.org/10.5114/pm.2017.68594.
The features of the studied population and its small simple size do not allow to
reach definitive conclusions but open to further critical trials. In conclusion, the
paper provided a precious focus on obesity in sexual minorities leading towards
a subpopulation prevention targeting.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
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from apparent manipulation?
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