Reviewer’s report
Title: 
The Association Between Sexual Orientation, BMI, Obesity Diagnosis,
and Provider Recommendation for Weight Management
Version: 
0 
Date: 
18 Jul 2021
Reviewer: 
Candice Belanoff
Reviewer's report:
The subject of equitable treatment of LGBTQ+ people is certainly a very
important one, and it is of interest to know how cis LGB women with obesity are
treated by the medical system. 
I have a couple overarching concerns with this paper. The problem I see here is
that the authors do not provide any substantiation for why this particular study
question is merited. It is not enough to say "little is known" about this topic. (i.e.
The reasoning is not clear for why the authors suspect that medical providers
might differentially diagnose and/or treat obesity among heterosexual vs. sexual
minority cis women. Are there other studies that have shown that providers
diagnose weight, eating or associated disorders differently by sexual orientation?
What's the underlying theory here? Do providers "see" obesity differently by the
sexual orientation of the patient? This needs some development and would set
up the study much more convincingly.
A number of other concerns/suggestions follow:
As the authors appropriately flag, there are a number of limitations to this study
& the measurement of the key dependent and independent variables. Small
numbers of LGB patients were certainly an issue. (Perhaps selecting the non-
LGB groups might have helped this issue if there had truly been a matching on
characteristics thought to likely confound the association of interest -- so say,
medical conditions, socioeconomic position, etc. Then you wouldn't have to
control for those things in your models.) The measure of sexual orientation is
self-reported, and while the setting may lead to more honesty that in, say, a less
LGBTQ+ friendly one, there is still likely under-reporting of sexual minority
status. (It would have been of interest to include folks who chose not to report on
their sexual orientation at all.) The authors note that a potential "bias" might be
introduced by providers offering counseling but not recording it. Do the authors
think that this would occur more often with one group or another? If not, the
question of "bias" may be better characterized by non-differential "under-
reporting" of service provision.)
Also of interest, did the authors consider examining differences in obesity
categories? For instance, you could have stratified (though I realize the cell sizes
may have been too small) by Obesity I, II, and III to see whether the association
differed at higher BMIs (where health concerns are greater). 
Though along those
lines, this study appears to be premised on the idea that most/all obese people
would be well-served by a doctor-recommended intervention. Is there evidence
to suggest that this is the best treatment approach? (Short of gastric bypass
surgery, I don't know of many doctor-assisted diet plans that work to reduce BMI
in the long run, though citing those would bolster your case/premise.) The
assertion that lives are being lost for lack of medical intervention around obesity
seems unsupported. (Though adequate treatment of associated disorders like
DM2, hypertension, etc, would certainly be important, regardless of BMI). 
Why were the multivariable tables relegated to the supplementary section? Their
findings were highlighted in the abstract and findings. 
Table 2 could use some additional labeling to make clear that the different n's for
straight women were due to the different samples selected for each comparison.
(That was only clear after I read the specifics of the methods, but many readers
go to the tables first for information.) I would also recommend consistently using
2 or fewer decimal places (and really I would go with one decimal place in your
descriptives) for such a small sample. 
The conclusion that "disparities do not exist in this urban population" should be
tempered and made more precise -- something like "we did not observe
disparities among this sample from an urban population of patients receiving
care in a university medical system...." etc etc. Be specific and make inferences
only as far a your sample allows. Of note, it would be of great interest going
forward to examine the experiences of people who are both sexual and racial
minorities for how they experience healthcare around weight management. 
In all, I would say this study would be greatly improved by simply making a
stronger case for this research question in the first place. What is the theoretical
framework driving this issue? What are the studies that have led to this being a
relevant next step in the field?
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Is the study design appropriate to answer the research question (including the use
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