The inclusion of sex and gender considerations and female representation in Nutrition and Dietetics journals: A comparison between 2012 and 2022

Abstract

Background:

Consideration of sex and gender in nutrition research is needed to inform best practice interventions and policy. It is unknown how nutrition and dietetic journals comply with sex and gender reporting guidelines.

Objective:

To determine if female representation and adherence to sex and gender guidelines across the leading nutrition and dietetic journals have changed between 2012 and 2022.

Design:

Quantitative analysis of articles published in 10 nutrition and dietetic journals was conducted. We screened a random sample of at least 100 articles per journal and year, aiming to include 50 randomly selected articles published in 2012 and 50 published in 2022 per journal. Articles were included if they were original research, conducted in humans, and focused on nutrition. Review articles and those focused on sex-specific conditions were excluded.

Methods:

Data were compiled on the proportion of female participants in published studies and compliance with the International Committee of Medical Journal Editors (ICMJE) guidelines relating to sex and gender. Changes in compliance with ICMJE guidelines between 2012 and 2022 were assessed using chi-square tests.

Results:

A total of 812 articles (402 in 2012, 410 in 2022) were included. Female representation was 56% in both years. Increases in adherence to ICMJE guidelines included reporting of sex and/or gender (90% in 2012 to 94% in 2022, p = 0.03), statistical comparison by sex and/or gender (38% in 2012 to 48% in 2022, p = 0.02), and definition of sex and/or gender terminology (0% in 2012 to 2% in 2022, p = 0.002). There was no evidence of a change in single-sex study justification, stratification of results by sex and/or gender, justification if not stratified, and discussion of sex and/or gender-related factors between time points.

Conclusion:

Greater inclusion of sex and gender considerations in nutrition research is required to inform best practice interventions.

Plain language summary

How sex and gender are reported in nutrition and dietetic journals: Comparing 2012 and 2022

It’s important to consider sex and gender in nutrition research to create effective interventions and policies. However, it’s unclear how well nutrition and dietetic journals follow guidelines for reporting sex and gender. We aimed to see how female representation and adherence to sex and gender guidelines in top nutrition and dietetic journals changed from 2012 to 2022. We reviewed ten leading journals, by randomly selecting up to 50 published articles per journal and per year (2012 and 2022). We included original research focused on nutrition and excluded review articles and studies on sex-specific conditions like endometriosis. In total 812 articles were reviewed (402 from 2012 and 410 from 2022). Female representation stayed at 56% in both years. There were small improvements in reporting sex and/or gender (from 90% in 2012 to 94% in 2022), comparing results by sex and/or gender (from 38% in 2012 to 48% in 2022), and defining sex and/or gender terms (from 0% in 2012 to 2% in 2022). However there was no increase in justifying why studies included only one sex, separating results by sex or gender, explaining why results were not separated, or discussing sex and gender-related effects on results. More attention to sex and gender in nutrition research is needed to improve interventions and policies.

Keywords

nutrition dietetics sex and gender guidelines

Introduction

Sex and gender have an important influence on health behaviours, access to care, treatment, and outcomes across many conditions.¹ Yet, research has historically overlooked these influences, with females underrepresented in medical studies.² This lack of representation has contributed to inequities in health outcomes in diet-related diseases for females and gender-diverse individuals,^3–5 including delayed diagnosis and treatment of heart disease.⁶ Advocacy over recent decades has driven policies and guidelines requiring sex and gender considerations to ensure research findings are relevant and equitable.^7–9 At a global level, the UN Sustainable Development Goals (SDGs) position gender equality as both a standalone target and a foundation for achieving the other goals.^10,11 Progress toward these goals requires monitoring progress through a sex- and gender lens.

Diet is a leading global risk factor for death and disability, with poor diets contributing to 11 million deaths and 255 million disability-adjusted life years (DALYs) in 2017.¹² Sex and gender are important factors in nutrition research – from dietary patterns and food environments to health outcomes and public health strategies.¹³ Biological sex differences have been identified for nutrient needs, disease risk, and even taste preferences, while gender norms affect food choices, roles in meal preparation, and access to food during crises.¹³ Ignoring these factors risks producing dietary guidelines and interventions that are ineffective, or even harmful, for certain population groups.¹⁴ As with other health professions, nutrition and dietetics has been highlighted as a profession that lacks diversity.^15,16 This lack of diversity may shape how research is designed, conducted and reported and influence the development of dietary guidelines, including which population groups they address.^15,16

Since 2008, the International Committee of Medical Journal Editors (ICMJE) has encouraged researchers to analyse clinical trial data by sex, later expanding its guidelines in 2013 to require sex and gender reporting across all study types.^17,18 Building on this, the Sex and Gender Equity in Research (SAGER) guidelines, introduced in 2016, provide a systematic framework for authors and editors.⁷ While many leading nutrition and dietetics journals endorse these guidelines, it remains unclear whether this has translated into meaningful integration of sex and gender considerations in research or measurable progress over time. Therefore, this study aimed to assess how sex and gender are incorporated in nutrition and dietetics research publications and the representation of females/women included in studies published by leading journals, comparing a random sample of articles from 2012 and 2022.

Methods

We present a quantitative analysis of publications in the top 10 ranking Nutrition and Dietetics journals across two time points following previously published methods by Hallam et al.¹⁹ We have reported our findings in line with the STROBE guidelines as appropriate, Supplemental Table 1.²⁰ In this article, we use the terms sex and gender in line with their use in the ICMJE guidelines, whereby sex refers to biological differences while gender encompasses identity, psychosocial, and cultural roles and behaviours.¹⁸ Sex as a biological variable can encompass female, male and people with variations in sex characteristics and in data collection can refer to sex assigned at birth or self-reported sex, whereas gender identity can be related to, yet differ from biological sex with gender identity terms varying across cultures.²¹

Journal selection

The top 10 ranking Nutrition and Dietetics journals were selected based on the 2022 Scopus CiteScore.²² Journals that only published review articles were excluded, with the next highest-ranking journal selected as a replacement. The journals selected were the American Journal of Clinical Nutrition, Clinical Nutrition, European Journal of Nutrition, International Journal of Behavioural Nutrition and Physical Activity (ISBNPA), Obesity, Food Quality and Preference, Journal of Nutritional Biochemistry, European Journal of Clinical Nutrition, Journal of Functional Foods, and the International Journal of Obesity.

Selection of publications

Our approach to selecting publications follows methods previously published by Hallam et al.¹⁹ Research articles published by the top journals in 2012 and 2022 were identified from Scopus using the “article” filter. All articles from each journal and year were downloaded into an Excel spreadsheet. Given the high number of publications per year by some of the included journals, it was not feasible to include all articles. As such, a random selection approach was conducted, aiming for 50 included articles per journal, per year, to allow for comparisons between time points. The Excel “RAND()” function was used to randomise the journal publication list for each journal and year. The first 100 articles were then selected for title/abstract screening from each randomised publication list for 2012 and 2022, respectively. For journals where fewer than 50 articles from the initial samples of 100 articles screened met the inclusion criteria, a further random sample of 100 articles was screened. A maximum of 200 articles per journal were screened to identify up to 50 articles per journal to be included in the final analysis. For journals that published <100 articles per year, the full article list was included for title/abstract review (Figure 1 and Table 1).

Figure 1.

Flowchart depicting the randomised article sampling process, inclusion and exclusion numbers and reasons, and final inclusion numbers for articles published in selected journals in 2012 and 2022.

Table 1.

Screening results, by screening round, journal and year.

2012			2022
First round screening: Journals reaching 50 articles
American Journal of Clinical Nutrition	Screened: 100 Included: 50; excluded: 50		American Journal of Clinical Nutrition	Screened: 100 Included: 50; excluded: 50
	Wrong population	11		Wrong population	9
	Wrong publication type	21		Wrong publication type	12
	Wrong study design	9		Wrong study design	7
	Exceeding quota	10		Exceeding quota	22
Food Quality and Preferences	Screened: 100 Included: 50; excluded: 50		Food Quality and Preferences	Screened: 100 Included: 50; excluded: 50
	Wrong population type	2		Wrong study design	6
	Wrong study design	14		Exceeding quota	44
	Exceeding quota	34
European Journal of Clinical Nutrition	Screened: 100Included: 50; excluded: 50		European Journal of Clinical Nutrition	Screened: 100Included: 50; excluded: 50
	Wrong population	3		Wrong population	6
	Wrong study design	7		Wrong publication type	7
	Exceeding quota	40		Wrong study design	8
				Exceeding quota	29
Clinical Nutrition	Screened: 100Included: 50; excluded: 50		European Journal of Nutrition	Screened: 100Included: 50; excluded: 50
	Wrong population	4		Wrong population	4
	Wrong population type	19		Wrong population type	19
	Wrong study design	16		Wrong study design	15
	Exceeding quota	11		Exceeding quota	12
Second round screening
International Journal of Obesity	Screened: 145Included: 50; excluded: 95		International Journal of Obesity	Screened: 200Included: 50; excluded: 150
	Wrong population	3		Wrong population	5
	Wrong publication type	2		Wrong study design	145
	Wrong study design	90
Obesity	Screened: 186Included: 50; Excluded: 136		Obesity	Screened: 187Included: 50; Excluded: 137
	Wrong population	4		Wrong population	9
	Wrong publication type	12		Wrong publication type	43
	Wrong study design	120		Wrong study design	85
European Journal of Nutrition	Screened: 107 (total published)Included: 33; excluded: 74		Clinical Nutrition	Screened: 107Included: 50; excluded: 57
	Wrong population	7		Wrong population	2
	Wrong publication type	13		Wrong publication type	37
	Wrong study design	54		Wrong study design	18
International Journal of Behavioural Nutrition & Physical Activity	Screened: 152 (total published)Included: 48; excluded: 104		International Journal of Behavioural Nutrition & Physical Activity	Screened: 144 (total published)Included: 41; excluded: 103
	Wrong population	3		Wrong population	5
	Wrong publication type	21		Wrong publication type	34
	Wrong study design	80		Wrong study design	64
Journal of Functional Foods	Screened: 104 (total published)Included: 10; excluded: 94		Journal of Functional Foods	Screened: 200 (max screening)Included: 14; excluded: 186
	Wrong population	3		Wrong population	2
	Wrong study design	91		Wrong publication type	22
				Wrong study design	162
Journal of Nutritional Biochemistry	Screened: 200 (max screening)Included: 12; excluded: 188		Journal of Nutritional Biochemistry	Screened: 200 (max screening)Included: 12; excluded: 188
	Wrong population	1		Wrong population	4
	Wrong study design	9		Wrong publication type	10
	Wrong study design	178		Wrong study design	175

Articles were excluded if they were: review articles, essays, perspectives, commentaries, narrative reviews or abstracts (where the full text was not available, e.g., from conference presentations), articles that focused on sex specific conditions, and animal or cell studies. The exclusion of sex specific conditions was based on conditions or scenarios affecting reproductive organs (studies on nutrition in relation to prostate cancer, endometriosis, ovarian cancer, pregnancy and lactation). Articles were included if they were an original research article, with human participants, that had a nutrition element or focus (e.g., food-related preferences, nutritional intake, nutrition-related knowledge, behaviour, or attitudes, nutrition interventions, food policy, food policy interventions), and published in English between either 1 January 2012 to 31 December 2012, or 1 January 2022 to 31 December 2022. The title and abstract were screened against these criteria by JC and AP, with conflicts resolved by discussion and consensus with BLM.

Journal data extraction

In January 2023, each journal’s website and author submission guidelines were reviewed to determine whether they provided guidelines on sex and gender reporting for authors. Data were extracted by BLM.

Publication data extraction

The included articles were reviewed in full, with information extracted into a data extraction framework in excel. Information on the type of study was extracted (observational, intervention/experimental, randomised controlled trial (RCT)), the life stage of participants (children, adolescents, adults), the focus area of the study (e.g., micronutrient intake, macronutrient intake, dietary interventions, nutrition for specific health conditions), the total number of participants, and the number of females in each study. Data were then extracted on the compliance to sex and gender considerations with the ICMJE criteria,¹⁸ with the addition of a criteria around including sex and gender comparisons (Table 2).²³ Data were extracted separately from a sample of 10 articles by BLM and JC and 10 articles by BLM and AP and then results compared and any inconsistencies clarified. The remaining data extraction was conducted by BLM and JC.

Table 2.

International Committee of Medical Journal Editors criteria on sex and gender reporting in academic publications.

Question	ICMJE guide
Is the sex/gender of participants reported?	“Report the sex and/or gender of study participants, the sex of animals or cells”
If the study is only in one sex/gender, is it justified why?	“If the study was done involving an exclusive population, for example in only one sex, authors should justify why”
Are sex and gender defined? If so, how?	“Ensure correct use of the terms sex (when reporting biological factors) and gender (identity, psychosocial or cultural factors)”
Is it described how sex and gender are determined?	“Describe the methods used to determine sex and gender”
What proportion of the participants/subjects are women/female?	“Because the relevance of such variables as age, sex, or ethnicity is not always known at the time of study design, researchers should aim for inclusion of representative populations into all study types and at a minimum provide descriptive data for these and other relevant demographic variables.”
Are results reported stratified by sex/gender?	“Separate reporting of data by demographic variables, such as age and sex, facilitate pooling of data for subgroups across studies and should be routine, unless there are compelling reasons not to stratify reporting, which should be explained.”
If results are not stratified, is this justified?	“Separate reporting of data by demographic variables, such as age and sex, facilitate pooling of data for subgroups across studies and should be routine, unless there are compelling reasons not to stratify reporting, which should be explained.”
Is a statistical model or analysis conducted to determine the effect of sex and/or gender or conduct a comparison based on sex and/or gender?	“This point is not directly out of the ICMJE guidelines but was necessary to effectively capture different ways people were incorporating sex/gender into their results, following approaches conducted by other authors.”¹¹
Is the influence of sex/gender on the results discussed?	“Discuss the influence or association of variables, such as sex and/or gender, on your findings, where appropriate, and the limitations of the data.”

ICMJE, International Committee of Medical Journal Editors.

Data analysis

The percentage of female participants and adherence to the ICMJE guidelines for each criterion was calculated and reported using descriptive statistics, for 2012 and 2022 overall and by journal. Analyses comparing female representation and compliance with ICMJE guidelines across all the journals collectively between 2012 and 2022 was conducted using chi-square tests, except when any resultant 2x2 table had an expected value, under the null hypothesis of no association, below 5, in which case Fisher’s exact test was used. Analyses were conducted in Excel and in STATA version 18.0 (StataCorp LP, College Station, Texas). Differences in compliance to guidelines between the time points were considered significant when p < 0.05.

No ethical approval was required for this study.

Results

Journal policies

Of the 10 journals, 5 journals referred to the SAGER guidelines and encouraged authors to follow these guidelines, 4 journals referred to the ICMJE guidelines, 3 journals had specific references for how sex and gender should be defined in articles (by following World Health Organization, National Institutes of Health or journal specific definitions of sex and gender). One journal (European Journal of Nutrition) made no reference to sex and gender or guidelines that include sex and gender considerations in their editorial policies or guidance for authors at the time of assessment (Table 3).

Table 3.

Details of each included journal, eligible articles and journal guidelines around the inclusion of sex and gender considerations.^24-33

Journal	Year	Number of articles included	Guidelines, based on web search in 2023
American Journal of Clinical Nutrition	2012	50	Guidelines for authors make reference to the SAGER guidelines and the ICMJE guidelines. Sex and gender are described as important considerations.
American Journal of Clinical Nutrition	2022	50
Clinical Nutrition	2012	49	Guidelines for authors make reference to ICMJE and directs authors to definitions of sex and gender as defined by the WHO.
Clinical Nutrition	2022	48
European Journal of Clinical Nutrition	2012	50	Reference the ICMJE recommendations more generally (but not specific to sex and gender considerations).
European Journal of Clinical Nutrition	2022	49
European Journal of Nutrition	2012	33	None.
European Journal of Nutrition	2022	48	None.
Food Quality and Preference	2012	50	Guidelines for authors make reference to the SAGER guidelines and SAGER checklist.
Food Quality and Preference	2022	50
International Journal of Behavioural Nutrition and Physical Activity	2012	48	Authors are encouraged to follow the SAGER guidelines and make reference to the NIH definition of sex and gender.
	2022	41
International Journal of Obesity	2012	50	Guidance on the need to define sex and gender in studies, no other guidelines.
International Journal of Obesity	2022	50
Journal of Functional Foods	2012	10	Guidelines for authors make reference to the SAGER guidelines and SAGER checklist.
Journal of Functional Foods	2022	14
Journal of Nutritional Biochemistry	2012	12	Guidelines for authors make reference to the SAGER guidelines and SAGER checklist.
Journal of Nutritional Biochemistry	2022	12
Obesity	2012	50	Reference the ICMJE recommendations more generally (but not specific to sex and gender considerations).
Obesity	2022	48

SAGER, Sex and Gender Equity in Research; ICMJE, International Committee of Medical Journal Editors; WHO, World Health Organization; NIH, National Institutes of Health.

Publication characteristics

After screening, 812 articles were included (402 in 2012 and 410 in 2022). These were unevenly distributed between journals with only 10 from Journal of Functional Foods 2012 meeting the inclusion criteria (due to a high number of animal and cell studies), compared with the target 50 articles met for Obesity 2012, European Journal of Clinical Nutrition 2012, AJCN 2012 and 2022, Food Quality and Preference 2012 and 2022, and International Journal of Obesity 2012 and 2022 (Table 3).

Of the included articles for 2012, 206 were observational studies, 100 were intervention/experimental studies and 96 were RCTs. For 2022, 254 were observational studies, 65 were intervention/experimental studies, and 95 were RCTs. Collectively, these studies included 868,301,290 participants in 2012 (between 6 and 866,415,856 per study) and 11,343,865 participants in 2022 (between 7 and 5,109,468 per study).

Representation of females

There was no difference in the representation of females between the two time points across studies (56% in 2012 and 56% in 2022). In observational studies, 53% of participants in 2012 and 54% in 2022 were females, in intervention/experimental studies 60% of participants in 2012 and 59% in 2022 were females, and in RCTs 57% in 2012 and 59% in 2022 were females. There were differences in the representation of females observed between journals, ranging from 48% in 2012 from the Journal of Nutritional Biochemistry to 66% in 2022 from Obesity (Table 4).

Table 4.

Percentage of sampled articles meeting sex and gender reporting guidelines in 2012 compared with 2022 across leading nutrition and dietetic journals.

Journal	Year	Female (%)	Sex and/or gender reported, % (n/total)	Sex and/or gender defined, % (n/total)	Single-sex justification, % (n^justified/n^{single-sex studies})	Stratification of results by sex/gender, % (n^stratified/n^{multi-sex studies})	Justified not stratifying, % (n^justified)/n^{not stratified})	Statistical comparison by sex or gender, % (n^compared/n^{multi-sex studies})	Discussion of sex or gender factors, % (n/total)
American Journal of Clinical Nutrition	2012	51	96 (48/50)	0 (0/50)	20 (1/5)	29 (13/45)	25 (8/32)	33 (15/45)	34 (17/50)
	2022	50	94 (47/50)	0 (0/50)	17 (1/6)	27 (12/44)	9 (3/32)	34 (15/44)	38 (19/50)
	Δ%	−1	−2	0	−3	−2	−16	+1	+4
Clinical Nutrition	2012	50	88 (44/50)	0 (0/50)	17 (1/6)	21 (9/43)	0 (0/36)	28 (12/43)	26 (13/50)
	2022	47	100 (48/48)	0 (0/48)	25 (1/4)	41 (18/44)	0 (0/26)	84 (37/44)	23 (11/48)
	Δ%	−3	+12	0	+12	+20	0	+56	−3
European Journal of Nutrition	2012	58	91 (30/33)	0 (0/33)	29 (2/7)	35 (9/26)	0 (0/17)	31 (8/26)	33 (11/33)
	2022	56	94 (45/48)	0 (0/48)	11 (1/9)	31 (12/39)	4 (1/27)	36 (14/39)	27 (13/48)
	Δ%	−2	+3	0	−18	−4	+4	+5	+6
International Journal of Behavioural Nutrition and Physical Activity	2012	56	79 (38/48)	0 (0/48)	67 (4/6)	58 (23/40)	0 (0/19)	88 (35/40)	38 (18/48)
	2022	60	85 (35/41)	0 (0/41)	60 (3/5)	52 (17/33)	0 (0/14)	79 (26/33)	29 (12/41)
	Δ%	+4	+6	0	−7	−6	0	−9	−8
Obesity	2012	55	96 (49/50)	0 (0/50)	15 (2/13)	30 (11/37)	4 (1/26)	35 (13/37)	28 (14/50)
	2022	66	92 (44/48)	2 (1/48)	0 (0/3)	16 (7/45)	8 (3/38)	31 (14/45)	17 (8/48)
	Δ%	+11	−4	+2	−15	−14	+4	−4	−11
Food Quality and Preference	2012	62	80 (40/50)	0 (0/50)	0 (0/1)	13 (6/48)	7 (3/43)	21 (10/48)	14 (7/50)
	2022	56	98 (49/50)	6 (3/50)	100 (2/2)	23 (11/48)	3 (1/37)	40 (19/48)	34 (17/50)
	Δ%	−6	+18	+6	+100	+10	−4	+19	+20
Journal of Nutritional Biochemistry	2012	48	92 (11/12)	0 (0/12)	40 (2/5)	43 (3/7)	0 (0/4)	29 (2/7)	25 (3/12)
	2022	61	100 (12/12)	8 (1/12)	75 (3/4)	13 (1/8)	14 (1/7)	13 (1/8)	42 (5/12)
	Δ%	+13	+8	+8	+35	−30	+14	−16	+17
Journal of Functional Foods	2012	63	90 (9/10)	0 (0/10)	50 (2/4)	0 (0/6)	0 (0/6)	0 (0/6)	0 (0/10)
	2022	51	93 (13/14)	0 (0/14)	50 (1/2)	8 (1/12)	9 (1/11)	42 (5/12)	29 (4/14)
	Δ%	−12	+3	0	0	+8	+9	+42	+29
European Journal of Clinical Nutrition	2012	55	90 (45/50)	0 (0/50)	11 (1/9)	34 (14/41)	9 (2/27)	39 (16/41)	26 (13/50)
	2022	53	90 (44/49)	4 (2/49)	29 (2/7)	38 (16/42)	4 (1/26)	50 (21/42)	22 (11/49)
	Δ%	−2	0	+4	+18	+4	−5	+11	−4
International Journal of Obesity	2012	55	94 (47/50)	0 (0/50)	33 (3/9)	27 (11/41)	3 (1/30)	41 (17/41)	34 (17/50)
	2022	58	92 (46/50)	6 (3/50)	44 (4/9)	20 (8/41)	12 (4/33)	46 (19/41)	22 (11/50)
	Δ%	+3	−2	+6	+11	−7	+9	+5	−12
Total	2012	56	90	0	26	30	6	38	28
	2022	56	94	2	36	29	6	48	27
	Δ%	0	+4	+2	+10	−1	0	+10	−1

Sex and gender considerations included in articles and changes between 2012 and 2022

The number of articles that reported results by sex and/or gender increased from 90% (360/402) in 2012 to 94% (384/410) in 2022 (p = 0.03). No articles stated how they defined sex and gender in 2012, while 10 articles provided a definition in 2022 (2%, p < 0.002). Only one study (published in 2022) presented individuals who reported as an “other/non-defined” gender category, however this was not defined further. In 2012, 54% (35/65) of single-sex studies were in females, which increased to 60% (30/50) in 2022. Of these studies, in 2012 26% (17/65) provided justification for being conducted in a single-sex population, compared with 36% (18/50) in 2022 (p = 0.14). The frequency of stratifying results did not differ significantly between time points, with 30% (99/333) stratifying in 2012 and 29% (103/354) in 2022 (p = 0.60). Of the articles that could have, but did not, stratify results by sex/gender, a justification for not doing so was provided by 6% (15/238) in 2012 and 6% (16/251) in 2022 (p = 0.51). There was an increase in the number of articles that conducted a statistical comparison between sexes or by gender from 38% (128/333) in 2012 to 48% (169/354) in 2022 (p = 0.02). Finally, the frequency of discussing sex- and/or gender-related factors did not differ significantly between time points, occurring in 28% (113/402) of articles in 2012 and 27% (111/410) in 2022 (p = 0.95; Figure 2).

Figure 2.

Comparison of sex and gender considerations and compliance to ICMJE guidelines in Nutrition and Dietetics Journals, 2012 versus 2022 (%).

Results presented by journal and year are shown in Table 4. Key differences were observed by journal and by year. For example, the proportions of articles that presented findings stratified by sex or gender varied from as low as 0% in 2012 for the Journal of Functional Foods, up to 52% for articles in ISBNPA in 2022. Justification for not stratifying results was as low as 0% across four journals in 2012 and two journals in 2022. The highest proportion of articles that did provide justification for not stratifying was 25% in the American Journal of Clinical Nutrition 2012, and this decreased to 9% in 2022. The proportion of articles that conducted a statistical comparison by sex or gender increased between time points for most journals (n = 7). Clinical Nutrition saw the biggest increase in articles conducting sex and gender comparisons from 28% in 2012 to 84% in 2022. In contrast, three journals saw a decrease in the number of articles conducting statistical comparisons by sex or gender. Across all journals, less than two in five articles discussed sex and/or gender considerations and five journals saw a decrease in articles discussing sex and/or gender over time.

Discussion

This is the first study to quantitatively investigate the inclusion of sex and gender considerations in nutrition and dietetics journals. We found there was good representation of females overall in both years (56%). However, except for reporting the sex and/or gender of study participants, adherence to all other ICMJE guidelines on sex and gender reporting occurred in less than 50% of articles at both time points. Improvements between 2012 and 2022 were minimal, particularly given the 10 years between comparison points. The proportion of articles adhering to guidelines was found to vary across journals, and journal adherence was not consistent across the different ICMJE guideline criteria. These findings highlight the need for greater advocacy around the importance of including sex and gender considerations in nutrition-related studies. Greater advocacy and support for this is needed through all stages of the research cycle, from grant applications and study design to the editorial and peer review process with journals.

The lack of adherence to journal sex and gender guidelines, identified in this study, aligns with previous findings across medical journals. A 2023 study by Hallam et al. that looked at the 10 leading Australian health and medical research journals, found no increase in reporting or analysis of sex and gender in journals that contained ICMJE guidelines.²³ Merriman et al.’s 2021 review of 14 medical and global health journals likewise found that for the five journals that did explicitly encourage sex and gender reporting, there was no significant differences other than an increase in reporting participant sex and/or gender, compared to the other journals.³⁴ Our study saw minimal improvement in sex and gender reporting over a 10-year period. A mapping review of the Asia-Pacific region by Heffernan et al. similarly reported no improvement in the rate of sex and gender reporting in brain health over the past decade.³⁵ Likewise, a 2024 review of cardiovascular-related research published since 2015, when the UN SDG to promote gender equality was introduced, found that only 0.03% of publications considered gender equality.³⁶

Due to the diversity of nutrition research projects, there are occasions where full compliance with sex and gender guidelines may not be feasible, in which case the ICMJE guidelines stipulate that authors must justify the lack of compliance.¹⁸ Our study highlighted that most articles failed to justify why results were not stratified or why the study was conducted in a single-sex population. Justification for not meeting sex and gender criteria is necessary to highlight study limitations and to provide clarity and context for future use of the research.³⁷ Positively, we found that there was good representation of females in nutrition studies. This contrasts with other areas of medical research where females remain broadly under-represented.^38–40 Higher representation of females in most areas of nutrition may occur due to a reported higher level of interest in health, nutrition, and diets,⁴¹ and being more likely to self-opt to participate in surveys.⁴²

For nutrition research to be impactful, it is essential that at each stage of research, from capturing data through to publishing findings, individuals understand the role that sex and gender play in health and nutrition. While most health and research organisations define sex as referring to biological characteristics and gender as referring to social and behavioural characteristics, these terms are often mistakenly conflated in research.⁴³ We found that 97.6% of the 2022 articles reviewed still failed to define sex and/or gender or indicate which dimension may impact the study hypothesis. Hallam et al. likewise reported from a review of medical studies in Australia that sex and gender were undefined in all studies and inconsistently used in half.²³ Researchers and health professionals should be trained on the differences between sex and gender and encouraged to think critically about how they might influence study outcomes to ensure differences are appropriately captured in the collection, analysis and use of nutrition data.^15,16 The lack of diversity and representation in the dietetics profession may influence care and inclusive research practices.^15,16 While the coverage of intersectional inequities in studies was not a focus for the present study, there is a need to think about sex and gender within an intersectional framework to encourage research and evidenced informed practice that is equitable, and the development of dietary guidelines that are inclusive of, and responsive to, a population’s needs.

Addressing existing sex and gender gaps in health research requires a shared commitment by all relevant organisations. Research institutes should provide education and support to ensure that sex and gender are considered early in the research process. Journals need to take active steps beyond merely setting guidelines to provide authors, editors, and reviewers with adequate training and support to ensure manuscripts adhere to guidelines including the ICMJE. For example, Nature Journals actively prompt submitting authors to answer how sex and gender were considered in the study design.⁴⁴ Research funders also play a critical role in ensuring that the research they fund pays thoughtful attention to sex and gender. The Canadian Institute of Health and Research launched its Sex-and-Gender-Based Analysis in Research Plan which requires incorporation of sex and/or gender considerations in grant applications, they also provide online training and resources.⁴⁵ Evaluation of the programme has shown it to be highly effective which paves the way for other funders.⁴⁶ The National Institutes of Health have endorsed guidelines developed by the National Academies of Science, Engineering and Medicine (NASEM). The guide on “Measuring Sex, Gender Identity, and Sexual Orientation” was released in 2022 and builds on the SAGER guidelines in terms of providing specific advice on capturing respondent’s sex, gender identity and sexual orientation within studies.²¹ How the NASEM guide could and should be applied to nutrition research has been illustrated by Schier et al.,⁴⁷ in line with the Academy of Nutrition and Dietetics’ commitment to inclusion, diversity, equity, and access. The Australian National Health and Medical Research Council recently released a statement encouraging funding applicants to use consistent definitions and classifications of sex and gender, to consider sex and gender in the research question, and to stipulate how potential differences between different sex and gender groups will be measured and reported.⁴⁸

Policies and interventions that take sex and gender into consideration are more likely to be effective and benefit all people, including previously underrepresented populations.^43,48 Historical neglect of sex and gender in medical research has led to extensive gaps in knowledge, that have resulted in less effective healthcare and increased risk for underrepresented population groups, including both males and females, people with variations of sex characteristics, and people of diverse identities.⁴⁰ Recognising the gendered dimensions of nutrition is fundamental to achieving the UN SDGs.⁴⁹ Gender equality and nutrition together play a central role in achieving zero hunger, improved health and well-being, enhanced educational and work productivity, less poverty, and reduced inequalities.^10,50 Failing to integrate sex and gender into nutrition research reduces the potential effectiveness of policies and interventions and risks reinforcing sex and gender inequities.⁵¹

Strengths and limitations

This study was the first to assess sex and gender reporting in nutrition and dietetic journals. A randomised selection approach was used to select articles to audit journal compliance with guidelines. The use of two time points 10 years apart allowed us to detect improvements since the release of the updated ICMJE guidelines in 2013 and the SAGER guidelines in 2016. This allowed a minimum of 5 years between guideline release and study publication; we considered this sufficient time for studies to consider the guidelines; however, we did not assess when journals incorporated the guidelines and whether they were in place prior to the submission of each article assessed. Some of the guidelines including “discussing sex and gender considerations” are subjective, which was addressed by discussing data extraction approaches and reaching a consensus between authors. Due to our focus being on journal compliance, we did not conduct a risk of bias assessment or assess individual study quality and validity of findings. We also only assessed whether statistical analysis by sex or gender was conducted and did not look at whether the comparison conducted was appropriate. We were interested in identifying the representation of females, women, and girls across studies, given their historical underrepresentation in medical research; however, our findings were complicated by the fact that a very limited number of studies defined whether they were looking at sex or gender, how these data were collected or how participants were asked to report their sex/gender (e.g., if they were asked to report their sex at birth, self-reported sex or gender identity). The terms “female” and “woman” and “sex” and “gender” were often used interchangeably within studies. As such we have reported on “female representation” within this study, but this could include both people whose biological sex is female and people who identify as female/as a woman. Given the way that data on sex and gender was defined and recorded in the included studies, we were not able to explore the inclusion of intersex and non-binary individuals. However, it is imperative that all sex and gender populations are represented in nutrition research and future research should endeavour to include these populations. We acknowledge that there were limitations to our approach to excluding sex-specific conditions based on conditions related to reproductive organs. This exclusion was decided on when considering the ICMJE guidelines, as we did not expect studies on these conditions to have a comparison group of a different sex/gender or justify why they focused on a specific sex/gender within their studies. However, conditions that affect reproductive organs may be experienced by trans and intersex individuals whose identity does not align with binary sex specific classifications. This information would have been missed from our study but is an important focus in line with advocating for the uptake of more inclusive guidelines for measuring sex and gender in research, such as the NASEM guidelines.²¹ We also excluded all non-human studies which led to journals with higher proportions of articles focused on animal and cell studies having low numbers of included studies reducing the ability to make fair comparisons between journals. Future research should ensure sex and gender consideration are being adhered to in animal and cell studies.

Conclusion

This study highlighted that despite most of the leading nutrition and dietetic journals containing guidelines on sex and gender reporting, there remains limited adherence to guidelines with minimal improvements in the last 10 years. Concerted efforts are required by all stakeholders involved in nutrition-related research to improve endorsement and application of sex and gender policies and guidelines. Collaborative efforts are required to raise awareness of the integral role that sex and gender play in health and nutrition and to ensure that considerations of sex and gender are embedded in each stage of the research. It is essential to prioritise sex and gender considerations in nutritional research, policies, and interventions to ensure that the best health outcomes are achieved for all people regardless of their sex or gender.

Supplemental Material

sj-docx-1-whe-10.1177_17455057261426219 – Supplemental material for The inclusion of sex and gender considerations and female representation in Nutrition and Dietetics journals: A comparison between 2012 and 2022

Supplemental material, sj-docx-1-whe-10.1177_17455057261426219 for The inclusion of sex and gender considerations and female representation in Nutrition and Dietetics journals: A comparison between 2012 and 2022 by Briar L. McKenzie, Juliette Crowther, Aliyah Palu, Ana-Catarina Pinho-Gomes, Jacqui Webster and Mark Woodward in Women's Health

Footnotes

Acknowledgements

None.

ORCID iDs

Briar L. McKenzie

Juliette Crowther

Ethical considerations

Data were sourced from published studies; ethics approval was not required.

Consent to participate

There was no interaction with participants, collecting participate consent was not applicable to this study.

Consent for publication

Not applicable.

Author contributions

Briar L. McKenzie: Methodology; Data curation; Investigation; Formal analysis; Writing – original draft; Writing – review & editing; Visualisation.

Juliette Crowther: Data curation; Formal analysis; Writing – original draft; Writing – review & editing.

Aliyah Palu: Data curation; Writing – review & editing.

Ana-Catarina Pinho-Gomes: Writing – review & editing.

Jacqui Webster: Writing – review & editing; Supervision.

Mark Woodward: Conceptualisation; Methodology; Formal analysis; Supervision; Writing – review & editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: BLM is supported by a National Heart Foundation Postdoctoral Research Fellowship (APP106651). JW is supported by a National Health and Medical Research Fellowship (L2) (#2018015).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

Supplemental material

Supplemental material for this article is available online.

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