RESEARCH ARTICLE
Extreme Weight-Control Behaviors and Suicide Risk Among High School Students EMILY R. JOHNSON, MS, CHESa ROBERT M. WEILER, PhD, MPHb TRACEY E. BARNETT, PhDc LISA N. PEALER, PhDd
ABSTRACT BACKGROUND: Suicide is the third leading cause of death for people ages 15-19. Research has established an association across numerous risk factors and suicide, including depression, substance abuse, bullying victimization, and feelings of alienation. However, the connection between disordered eating as manifested in extreme weight-control behaviors (EWCB), and suicidal thoughts, ideation, and attempts among adolescents is less understood. Given the prevalence of adolescent suicide, this investigation examined associations between EWCB and suicide risk among high school students. METHODS: Data were collected from a convenience sample of 4178 students in grades 9-12 attending 5 public high schools using the Youth Risk Behavior Survey (YRBS) questionnaire. Logistic regressions were used to estimate associations between EWCB and suicide controlling for grade level and race, reported separately by sex. RESULTS: Students who reported seriously considering suicide had higher odds of exhibiting all 3 EWCBs [adjusted odds ratio (AOR)(male) = 3.0 (confidence interval (CI): 1.4, 6.5); AOR(female) = 4.5 (CI: 2.5, 8.3)]. Moreover, students who reported they made plans about suicide were also more likely to exhibit all EWCBs [AOR(male) = 3.7 (CI: 1.7, 7.9); AOR(female) = 4.2 (CI: 2.3, 7.7)]. CONCLUSIONS: EWCBs were significantly associated with suicide risk, furthering the evidence suggesting a link between disordered eating and suicide. Findings demonstrated the need for school health services that address disordered eating in the effort to reduce adolescent suicide. Keywords: suicide; suicidality; weight-control behaviors; unhealthy eating; health risk; adolescents; high school students; teenagers; survey research; Youth Risk Behavior Survey. Citation: Johnson ER, Weiler RM, Barnett TE, Pealer LN. Extreme weight-control behaviors and suicide risk among high school students. J Sch Health. 2016; 86: 281-287. Received on September 29, 2014 Accepted on November 9, 2015
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outh suicide is a serious public health problem as more adolescents die from suicide in the United States than from all leading natural causes of death combined.1,2 Resulting in approximately 1600 lives lost annually,3 suicide is currently the third leading cause of death for youth between the ages of 1519. Among females ages 15-19, suicide is the second leading cause of death; it is the third leading cause of death among males between the ages of 15 and 19.2,4 Suicides among youth between the ages of 1524 comprise 12% of all suicide deaths in the United
States1 and these rates reflect a 3-fold increase over the past 45 years.1,5 Risk factors associated with suicide include depression,3,6,7 feelings of hopelessness,3,8,9 physical or chronic illness,5,9 family history of suicidal behavior,3,9 limited social support and social isolation,8,10 poor coping skills,8 alcohol and substance use,10-12 risky sexual behaviors,13,14 and poor body image.4,6,15-17 For example, one study examining a cohort of 1000 adolescent boys and girls found a higher rate of suicidal behaviors in those scoring high
a Doctoral Candidate, ([email protected]fl.edu), Department of Health Education & Behavior, College of Health and Human Performance, University of Florida, PO Box 118210, 1864 Stadium Road, Suite 106K, Gainesville, FL 32611. b Professor and Chair, ([email protected]), Department of Global and Community Health, College of Health and Human Services, George Mason University, 4400 University Drive, MS 5B7, Fairfax, VA 22042. c Assistant Professor, ([email protected]fl.edu), Department of Behavioral Science and Community Health, College of Public Health and Health Professions, University of Florida, PO Box 100175, 1225 Center Drive, Gainesville, FL 32610. dSenior Public Health Consultant, ([email protected]), Hassett Willis, 1100 New York Avenue, NW, Washington, DC 20005.
Address correspondence to: Emily R. Johnson, Doctoral Candidate, ([email protected]fl.edu), Department of Health Education & Behavior, College of Health and Human Performance, University of Florida, PO Box 118210, 1864 Stadium Road, Suite 106K, Gainesville, FL 32611. Partial funding for this study was provided by Purdue Pharma, L.P., Stamford CT (Grant # NED 1022329). Robert M. Weiler, Principal Investigator.
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on the body attitudes test,18 indicative of high body dissatisfaction.19 A growing body of evidence suggests that some individuals may be predisposed to suicidal behaviors and are more likely to engage in suicidal ideation, thoughts, and attempts in response to stressors.20 Among girls, body image and weight-control behaviors appear to be 2 discrete stressors that may trigger a preexisting diathesis for suicide behavior.20-22 Zhang’s Strain Theory of Suicide also explains the role of strain or stressors resulting from psychological suffering23 and posits that unrealistic body image and weight-control behaviors are significantly correlated with suicidal behaviors.16 Furthermore, research has shown that whereas adolescent boys are more likely to die from suicide, girls are more likely to plan and attempt suicide.9,17 Dieting for weight control or weight loss is a commonly reported practice among adolescents24 and weight-control practices could be viewed as either health-promoting or risk-taking behaviors.25 However, extreme weight-control behaviors (EWCB), such as the use of laxatives or diet pills, skipping meals or fasting, and purging are associated with the initiation of risk-taking behaviors, which can lead to serious negative health outcomes.26 In one prospective study, dieting was associated with an 8-fold increase in developing an eating disorder over a 1-year period26 and reports show that approximately 20-25% of ‘‘normal dieters’’ progress to partial or full-syndrome eating disorders.27 Furthermore, preoccupation with weight and unhealthy weightcontrol behaviors can initiate numerous other negative behaviors, including smoking,13 alcohol and drug use,13 risky sexual practices,28-31 and suicide.13 The personal consequences and societal burden resulting from these behaviors are well-known, and as result, have been the focus of numerous school and public health prevention policies, programs, and healthrelated services. Although numerous studies have identified the association of an increased risk for eating disorder symptoms with excessive weight and shape concerns and unhealthy weight-loss behaviors in adolescents,9,26,32-35 research regarding the role of EWCB on suicide has been limited. This study examined the relationship of EWCB and suicidal thoughts, ideation, and attempts among high-school students in the United States. The overall aim of the study was to determine if adolescents who engage in EWCB are at a greater risk for suicide than those not engaging in EWCB. We hypothesized that there would be a significant association between EWCB and suicidal thoughts and actions, and that those who engage in EWCB are at a greater risk for suicide than those who do not engage in EWCB. Moreover, in line with previous research,17,19,36-38 we hypothesized that girls 282 •
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would be more likely to report using weight-control behaviors, and therefore, would be more likely to report engaging in EWCB. Finally, we hypothesized that more girls would report planning and attempting suicide than boys.
METHODS Participants Data were collected during fall 2010 and spring 2011. The convenience sample included 4148 students in grades 9-12 enrolled in 5 public high schools in 5 states (California, Florida, Illinois, New Jersey, and West Virginia). The Youth Risk Behavior Survey (YRBS)39 was used as an anonymous, groupadministered, cross-sectional survey. The schools were selected to obtain a large and diverse group of participants to support the aims of a larger study. The dates and class periods of data collection were arranged to accommodate individual school schedules. Schools received a stipend and a needs assessment report for their participation. Instrumentation Demographic data were assessed using 3 selfreported questions from the YRBS: (1) ‘‘What is your sex?’’ (female/male); (2) ‘‘In what grade are you?’’ (9th/10th/11th/12th); and (3) ‘‘How do you describe yourself (select only 1 response)?’’ (American Indian or Alaska Native/Asian/Black or African American/Hispanic or Latino/Native Hawaiian or Other Pacific Islander/White/Other). Owing to low prevalence, some categories required combining for appropriate statistical analysis; thus, the final categories for race were: Black, Hispanic, White, and other. Weight-control behaviors were assessed using 3 questions from the YRBS: (1) ‘‘During the past 30 days, did you go without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?’’ (yes/no); (2) ‘‘During the past 30 days, did you take diet pills, powders, or liquids without a doctor’s advice to lose weight or keep from gaining weight? (Do not include meal replacement ® products such as Slimfast )’’ (yes/no); and (3) ‘‘During the past 30 days, did you vomit or take laxatives to lose weight or to keep from gaining weight?’’ (yes/no). Endorsing these behaviors (yes response) were used to identify the participant as engaging in that behavior. A composite variable, EWCB, was created by combining the responses for participants who responded ‘‘yes’’ to all 3 questions. Suicide risks behaviors were assessed using 4 questions from the YRBS: (1) ‘‘During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you
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stopped doing some usual activities?’’ (yes/no); (2) ‘‘During the past 12 months, did you ever seriously consider attempting suicide?’’ (yes/no); (3) ‘‘During the past 12 months, did you make a plan about how you would attempt suicide?’’ (yes/no); and (4) ‘‘During the past 12 months, how many times did you actually attempt suicide?’’ (‘0 times,’ ‘1 time,’ ‘2 or 3 times,’ ‘4 or 5 times,’ ‘6 or more times’)?’’ For this analysis, the response options were dichotomized into ‘‘0 times’’ and ‘‘1 or more times’’ with participants who reported 0 times serving as the referent group.10 In a 2000 study conducted by the Centers for Disease Control and Prevention (CDC), the weight control and suicide risk questions demonstrated modest to substantial test-retest reliability39 as measured by the kappa statistic and using the qualitative benchmarks suggested by Landis and Kock.40,41 Kappas for the 3 weight-control questions ranged from 40.1 to 42.1 (moderate reliability). Kappas for the 4 suicide risk questions ranged from 56.4 (moderate reliability) to 74.3 (substantial reliability). Data Analysis Data were analyzed using SAS 9.4 for Microsoft ® Windows . Descriptive summary statistics were generated to examine all variables. Independent logistic regression models were constructed to measure associations between the weight controls behaviors and the suicide risk behaviors (feeling sad or hopeless every day for 2 or more weeks in a row, seriously consider attempting suicide, planning a suicide attempt, and actually attempting suicide). Models were separated and are presented by sex. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated, controlling for grade level and race/ethnicity. Participants who responded ‘‘no’’ to the ‘‘yes/no’’ questions served as the referent group. Alpha ≤ .05 were considered statistically significant.
RESULTS Nearly half of the participants were white (48.4%), 19.2% were black, 14% were Hispanic, and 18.4% were other race/ethnicity. Just over half of the participants were girls (51.7%). Among all participants, 12.7% reported fasting for at least 24 hours in the past 30 days, 5.3% used diet pills, powders, or liquids in the past 30 days, and 5.2% vomited or used laxatives during the past 30 days to keep from gaining weight. Of all participants, 77 (2%) were at risk for all 3 EWCB (Table 1). Girls were more likely to report fasting to lose weight compared with boys (69.9% versus 30.1%; X2 = 68.6, p < .0001) (Table 2). Girls were also more likely to report using diet pills, powders, or liquids (67.0% versus 33.0%, X2 = 18.0, p < .0001). Girls more often reported vomiting or taking laxatives for weight control (71.2% versus 28.8%, Journal of School Health
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Table 1. Participant Demographics and Weight-Control and Suicide Risks (N = 4148) Characteristics
N (%)
Sex Boys 2004 (48.3) Girls 2144 (51.7) Grade 9 1122 (27.1) 10 1142 (27.6) 11 1004 (24.2) 12 874 (21.1) Race Black 794 (19.2) Hispanic 581 (14.0) White 2004 (48.4) Other 764 (18.4) Weight-control behaviors Fast during past 30 days to keep from gaining weight No 3478 (87.3) Yes 505 (12.7) Diet pills during past 30 days to keep from gaining weight No 3772 (94.8) Yes 209 (5.3) Vomit during past 30 days to keep from gaining weight No 3755 (94.8) Yes 206 (5.2) Risk for all 3 weight-control behaviors, calculated No 3866 (98.1) Yes 77 (2.0) Suicide risk behaviors Feelings of hopelessness in past 12 months No 2893 (69.7) Yes 1257 (30.3) Considered suicide in the past 12 months No 3435 (82.8) Yes 715 (17.2) Planned suicide in past 12 months No 3543 (85.5) Yes 603 (14.5) Attempted suicide in the past 12 months No 3547 (85.2) Yes 614 (14.8)
X2 = 29.7, p < .0001). Reporting all 3 disordered eating patterns (EWCB composite) however, showed no differences between girls (58.4%) and boys (41.6%). Grade level was associated with being at risk for all 3 weight-control behaviors, with 39.2% of 9th graders reporting risk, compared with 18.9% of 10th graders, 17.6% of 11th graders, and 24.3% of 12th graders (X2 = 8.2, p < .05). Among all participants, 30.3% reported feelings of hopelessness, 17.2% reported considering suicide, 14.5% planned suicide, and 14.8% had attempted suicide at least once during the past 12 months preceding the administration of the survey (Table 1). Girls were more likely to report feelings of hopelessness in the past 12 months compared with boys (64.1% versus 35.9%; X2 = 109.2, p < .0001). Girls were more likely to have considered suicide in the past 12
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Table 2. Prevalence of Disordered Eating and Suicide Risk Behaviors Variable
Boys N = 2004 (%)
Girls N = 2144 (%)
Disordered eating variables (IV) Went without eating ≥24hours No 1727 (49.9) 1733 (50.1) Yes 151 (30.1) 350 (69.9) Took diet pills, powders, or liquids No 1808 (48.2) 1945 (51.8) Yes 68 (33.0) 138 (67.0) Vomit or took laxatives No 1804 (48.3) 1930 (51.7) Yes 59 (28.8) 146 (71.2) Risk for all 3 weight-control behaviors, calculated No 1820 (47.3) 2025 (52.7) Yes 32 (41.6) 45 (58.4) Suicide risk behaviors (DV) Feelings of hopelessness in past 12 months No 1543 (53.6) 1334 (46.4) Yes 448 (35.9) 799 (64.1) Considered suicide in past 12 months No 1736 (50.9) 1677 (49.1) Yes 257 (36.3) 451 (63.7) Planned suicide in last 12 months No 1762 (50.0) 1759 (50.0) Yes 229 (38.4) 368 (61.6) Attempted suicide in past 12 months No 1702 (48.3) 1825 (51.7) Yes 294 (48.5) 312 (51.5)
Chi-Square
68.6 (p< .0001)
18.0 (p< .0001)
29.7 (p< .0001)
n.s.
109.2 (p< .0001)
49.8 (p< .0001)
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Sad or hopeless every day for 2+ weeks Went without eating ≥24 hours Took diet pills, powders, or liquids Vomit or took laxatives Extreme—did all 3 Seriously considered attempting suicide Went without eating ≥ 24 hours Took diet pills, powders, or liquids Vomit or took laxatives Extreme—did all 3 Made a plan about committing suicide Went without eating ≥24 hours Took diet pills, powders, or liquids Vomit or took laxatives Extreme—did all 3 Attempted suicide Went without eating ≥24 hours Took diet pills, powders, or liquids Vomit or took laxatives Extreme—did all 3
Boys Adjusted + Model OR (CI)
Girls Adjusted + Model OR (CI)
4.0 (2.8-5.6) 3.3 (2.0-5.4) 4.4 (2.6-7.6) 3.4 (1.7-7.0)
3.6 (2.8-4.5) 3.7 (2.5-5.3) 3.8 (2.7-5.5) 5.1 (2.6-10.2)
4.0 (2.8-5.9) 3.1 (1.8-5.3) 4.1 (2.4-7.3) 3.0 (1.4-6.5)
3.6 (2.8-4.6) 2.7 (1.9-3.9) 3.5 (2.5-5.0) 4.5 (2.5-8.3)
4.1 (2.8-6.1) 3.1 (1.8-5.5) 3.0 (1.6-5.6) 3.7 (1.7-7.9)
3.0 (2.3-4.0) 2.8 (1.9-4.0) 3.8 (2.7-5.5) 4.2 (2.3-7.7)
1.6 (1.0-2.4) 1.1 (0.6-2.2) 3.2 (1.8-5.6) 1.9 (0.8-4.3)
2.8 (2.1-3.7) 2.9 (2.0-4.3) 2.8 (1.9-4.1) 4.5 (2.5-8.4)
27.9 (p< .0001)
n.s.
months (63.7% versus 36.3%, X2 = 27.9, p < .0001) and also to have planned suicide in the past 12 months (61.6% versus 38.4%, X2 = 27.9, p < .0001). There were no differences between girls and boys, however, for attempting suicide in the past 12 months (51.5% versus 48.5%, respectively) (Table 2). There was an association between grade level and considering suicide. Specifically, 9th graders reported the highest risk (29.6%), followed by 11th graders (26.6%), then 10th graders (24.3%), and 12th graders (19.5%) (X2 = 8.0, p < .05). Considering suicide in the past 12 months also displayed race/ethnicity differences (X2 = 9.3, p < .05), such that Whites reported the highest risk (47.1%), followed by other races/ethnicities (22.3%), Blacks (17.4%), and Hispanics reporting the lowest risk (13.2%). Planning suicide also was associated with race/ethnicity differences (X2 = 14.9, p < .01) similar to considering suicide; Hispanics reported the lowest (15.8%) and Whites reported the highest (42.6%). There were no race or grade differences for suicide attempts. In models adjusting for grade and race (Table 3), boys and girls who reported feeling sad or hopeless had higher odds of going without eating for more than 24 hours using diet pills, powders, or liquids and vomiting or taking laxatives. Students who reported 284
Table 3. Adjusted Odds Ratios (OR) and 95% Confidence Intervals (CIs) for Reporting Extreme Weight-Control Behaviors by Sex
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feeling sad or hopeless also had higher odds of exhibiting EWCB (all 3 EWCB) [AOR(male) = 3.4 (CI: 1.7, 7.0); AOR(female) = 5.1 (CI: 2.6, 10.2)]. Students who reported seriously considering attempting suicide, as well as reported making a plan about suicide, exhibited higher odds of going without eating for more than 24 hours, using diet pills, powders, or liquids, and vomiting or taking laxatives. Students who reported seriously considering suicide had higher odds of exhibiting EWCBs [AOR(male) = 3.0 (CI: 1.4, 6.5); AOR(female) = 4.5 (CI: 2.5, 8.3)] and students who reported they made plans about suicide were also more likely to exhibit EWCBs [AOR(male) = 3.7 (CI: 1.7, 7.9); AOR(female) = 4.2 (CI: 2.3, 7.7)]. Students who reported attempting suicide were at higher odds of going without eating for more than 24 hours, using diet pills, powders, and liquids, and vomiting or taking laxatives. Moreover, those who reported attempting suicide were also more likely to have exhibited all EWCBs [AOR(male) = 1.9 (CI: 0.8, 4.3); AOR(female) = 4.5 (CI: 2.5, 8.4)].
DISCUSSION According to 2011 national estimates, nearly 8% of high school students self-reported having attempted suicide 1 or more times in the previous 12 months, and of those attempts, 2% resulted in serious injury that required medical care.24 Someone in the United States commits suicide every 13.7 minutes, and for each youth suicide, an estimated 200 youth make a © 2016, American School Health Association
suicide attempt.4 Our study also identified a positive association between each disordered eating variable, as well as the composite EWCB and suicide among adolescents. Research indicates that early adolescence is a critical time for children because it is the period in which they are developing their sense of self-worth.42 Sense of self-worth, as well as self-esteem, can be considered key indicators for mental and emotional health, and can contribute to social success and well-being.42 Adolescence is also a vulnerable time in regards to body image. Satisfaction with physical appearance is an important determinant in sense of self42 and body image, or how you view your body. Your level of comfort with yourself, is developed over time as a result of outside influences, such as media portrayal and messages from other. In one survey that polled 3300 girls and women in 10 countries around the world, more than 90% of girls aged 15 to 17 years wanted to change at least one aspect of their physical appearance, with body weight ranking the highest.43 Whereas girls tend to experience greater discomfort and dissatisfaction with their changing bodies than do boys, a negative body image is prevalent in males as well.44 Although more than two-thirds of all participants that reported practicing any EWCB were girls, information regarding the importance of healthy eating habits and positive body image among all adolescents is crucial. To build feelings of selfworth, body image, and self-esteem, positive messages should be portrayed beginning in early childhood and throughout adolescence. Moreover, our findings support the need to consider body image as a component of self-harm behavior. Researchers have reported that suicidal adolescents report more negative body image, that body dissatisfaction is predictive of suicidal ideation beyond depression and hopelessness, and that suicidal adolescents with a negative body image exhibit higher levels of dissociation.8,44,45 This, along with the association between thoughts of suicide and feelings of hopelessness with the use of all 3 EWCB, demonstrates the need for programs that address these problems, as well as increased awareness and recognition in the health field. It is also important to note the association between suicide, depression, and trauma. Adverse childhood experiences (ACEs), such as early violent episodes in the home, can constitute risk factors for suicide46 and have been found to be associated with a variety of poor outcomes.47 These events can also, in turn, result in adolescent depression and suicidality. It is impossible to know if these ACEs and coinciding depression actually lead to an increased propensity to adolescent obesity, and eventually, patterns of EWCB. However, the link between trauma, depression, and obesity is probable. Journal of School Health
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Limitations Several limitations should be considered when weighing the implications of the current findings. First, the measures used were not designed to measure subclinical conditions or symptoms related to depressive disorders, suicide risk, or disordered eating. Rather the findings of this study are based on the analysis of measures contained in the YRBS which are designed to determine the prevalence of risk factors associated with suicide and problem eating behaviors which can be used to assist in planning, implementing, and evaluating health promotion programs and policies. Relatedly, the YRBS version used in this study did not include other potentially mediating measures such as trauma and other mental health disorders that might have been useful in the explaining the associations between suicide risk and disordered eating. Thus, it would be inappropriate to interpret the findings beyond this purpose. Second, despite the large and diverse sample, the data for this study were collected from a convenience sample, limiting the generalizability of the findings. Thus, future research should consider conducting a replicationsecondary analysis of the 2015 YRBS to determine if the current findings hold. Third, the findings are based on retrospective, self-report, anonymous, groupadministered surveys. Although the survey protocol was constructed to ensure participant anonymity, some participants may have provided inaccurate responses due to the sensitivity of the questions. The findings are also susceptible to other weaknesses of cross-sectional studies which threaten the precision and validity of the findings, namely response bias resulting from poor recall. Conclusions This study is distinct in that it examined 3 different EWCB, separately and combined, with suicide risk factors among boys and girls across a broad range of racial/ethnic groups in a convenience sample of public high-school students. The findings showed that a proportion of both boys and girls in public high schools engaged in unhealthy weight-control behaviors and were thinking about, planning, or considered attempting suicide. Despite variations in prevalence, EWCB appeared to be associated with suicide ideation for both sexes, despite grade and race. As the suicide rate for adolescents continues to increase, it is important that any measured response address the intersection of body image, weight-control behaviors, emotional health, and suicide.
IMPLICATIONS FOR SCHOOL HEALTH To change complex behaviors, such as eating patterns, evidence-based programs and policy interventions in both schools and communities must be
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accompanied by an increase in resources for students, especially those suffering with mental health problems. Our findings support the need for improved access to mental health care workers and counselors, as well as universal programs regarding healthy eating habits and weight-management that can support students of all races/ethnicities in making health-promoting decisions. Furthermore, the early age of onset for these EWCB demonstrate the need for these programs to be introduced to students prior to high school. Programs would be most effective in middle school-aged students who are at a critical age in which body acceptance is being questioned.48-51 Moreover, not only should school programs emphasize the difference between healthy and unhealthy weight management practices, but also they should focus on implementing strategies that help children and youth develop a positive bodyimage, self-appreciation, and positive mental health. School districts may benefit from training teachers and school personnel to identify students engaging in EWCB and/or who may be at risk for suicide. Students may also be more comfortable discussing suicide ideation with teachers and school staff who are advocates for positive youth development. Educating decision makers, including school board members, about the support needed for those students struggling with feelings of hopelessness or suicide ideation is important for adopting effective evidence-based programs. As with many adolescent health issues, ameliorating the complex behaviors, and underlying depressive symptomatology associated with EWCB will require a multicommunity approach. Schools should ensure that health services and professionals are inclusive and affirming of their students’ needs, as well as prepared to provide community resources and support networks to those in need. In addition to traditional schoolbased programs, school-based health clinics (SBHCs), where they exist, provide an excellent setting where health care practitioners could provide evidencedbased, one-on-one brief interventions. SBHCs can also expand their referral network to include community health resources that provide related preventative and treatment services. Besides SBHCs, innovative approaches that maximize other community health resources (such as local health departments, health care systems, insurance providers) should be explored. Similarly, faith-based and youth organizations (such as The Boys and Girls Clubs of America), various parent groups and associations, and family centers, are other viable settings which may provide the structure for delivering effective programs and services. Human Subjects Approval Statement The data collection protocol for this study was approved by the Institutional Review Board at the University of Florida (Protocol #2010-U-0960). 286 •
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REFERENCES 1. McIntosh JL, Drapeau CW. U.S.A Suicide 2010: Official Final Data. Washington, DC: American Association of Suicidology; 2012. Available at: http://www.floridasuicideprevention. org/PDF/2010%20US%20Suicide%20Official%20Final%20 Data%20AAS.pdf. Accessed January 3, 2016. 2. Heron M. Deaths: Leading Causes for 2010. National Vital Statistics Reports. Volume 62, Number 6, Hyattsville, MD: National Center for Health Statistics; 2012. 3. US Centers for Disease Control and Prevention. Injury center: Violence prevention. Youth suicide. Available at: www.cdc.gov/violenceprevention/pub/youth_suicide.html. Accessed January 3, 2016. 4. Dave D, Rashad I. Overweight status, self-perception, and suicidal behaviors among adolescents. Soc Sci Med. 2009;68:16851691. 5. Heneghan HM, Heinberg L, Windover A, Rogula T, Schauer PR. Weighing the evidence for an association between obesity and suicide risk. Surg Obes Relat Dis. 2012;8:98-107. 6. Seo DC, Lee CG. The effect of perceived body weight on suicidal ideation among a representative sample of US adolescents. J Behav Med. 2013;36:498-507. 7. Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry. 2006;47:372-394. 8. Orbach I, Stein D, Shani-Sela M, Har-Even D. Body attitudes and body experiences in suicidal adolescents. Suicide Life Threat Behav. 2001;31(3):237-249. 9. Whetstone LM, Morrissey SL, Cummings DM. Children at risk: the association between perceived weight status and suicidal thoughts and attempts in middle school youth. J Sch Heath. 2007;77(2):59-66. 10. US Centers for Disease Control and Prevention. National Center for Injury Prevention and Control, Suicide Risk and Protective Factors. Available at: www.cdc.gov/violenceprevention/ suicide/riskprotectivefactors.html. Accessed April 3, 2014. 11. Dansky B, Brewerton T, Kilpatrick D. Comorbidity of bulimia nervosa and alcohol use disorders: results from the National Women’s Study. Int J Eat Disord. 2000;27:180-190. 12. Conason AH, Oquendo MA, Sher L. Psychotherapy in the treatment of alcohol and substance abusing adolescents with suicidal behavior. Int J Adolesc Med Health. 2006;18(1):9-13. 13. Rafiroiu AC, Sargent RG, Parra-Medina D, Drane WJ, Valois RF. Covariations of adolescent weight-control, health risk and health-promoting behaviors. Am J Health Behav. 2003;27(1):3-14. 14. Joiner TE, Sachs-Ericsson NJ, Wingate LR, Brown JS, Anestis MD, Selby EA. Childhood physical and sexual abuse and lifetime number of suicide attempts: a persistent and theoretically important relationship. Behav Res Ther. 2007;45:539-547. 15. Brausch AM. Evaluation of factors for depression and suicide in a community sample of adolescents: the role of body image, disordered eating, parent and peer support, and self-esteem. Published 2008. (Order No. 3324866, Northern Illinois University). ProQuest Dissertations and Theses, 151. Available at http://search.proquest.com/docview/304540878? accountid=10920. 16. Kim YJ, Moon SS, Kim MJ. Physical and psycho-social predictors of adolescents’ suicide behaviors. Child Adolesc Social Work J. 2011;28(6):421-438. 17. Eaton DK, Lowry R, Brener ND, Galuska DA, Crosby AE. Associations of body mass index and perceived weight with suicide ideation and suicide attempts among US high school students. Arch Pediatr Adolesc Med. 2005;159:513-519. 18. Probst M, Vandereycken W, Coppenolle HV, Vanderlinden J. The Body Attitude Test for patients with an eating disorder: psychometric characteristics of a new questionnaire. Eat Disord. 1995;3(2):133-144.
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19. Miotto P, De Coppi M, Frezza M, Preti A. Eating disorders and suicide risk factors in adolescents: an Italian community-based study. J Nerv Ment Dis. 2003;191(7):437-443. 20. Zhang J, Wierczorek W, Conwell Y, Tu XM. Psychological strains and youth suicide in rural China. Soc Sci Med. 2011;72: 2003-2010. 21. Forman VL. Correlates, classification, and clustering of disordered eating behavior in a nationally representative sample of United States high school students. 2002. (Order No. 3046452, The Johns Hopkins University). ProQuest Dissertations and Theses, 397-397. Available at http://search. proquest.com/docview/305575000?accountid=10920. 22. Marshall KJ. Body image, depressed mood, weight concerns, and risky sexual behaviors among female adolescents. Published 2006. (Order No. 3286589, University of North Texas Health Science Center at Fort Worth). ProQuest Dissertations and Theses, 89. Available at http://search.proquest. com/docview/304911895?accountid=10920. 23. Zhang J, Song Z. A preliminary test of the strain theory of suicide. Chin J Behav Med Sci. 2006;15:487-489. 24. Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States 2011. MMWR Morb Mortal Wkly Rep. 2012;61(SS-4):1-168. 25. Story M, Neumark-Sztainer D, Sherwood N, Stanf J, Murray D. Dieting status and its relationship to eating and physical activity behaviors in a representative sample of US adolescents. J Am Diet Assoc. 1998;98(10):1127-1135. 26. French SA, Leffert N, Story M, Neumark-Sztainer D, Hannah P, Benson PL. Adolescent binge/purge and weight loss behaviors: associations with developmental assets. J Adolesc Health. 2001;28:211-221. 27. Neumark-Sztainer D, Story M, Dixon LB, Murray DM. Adolescents engaging in unhealthy weight control behaviors: are they at risk for other health-compromising behaviors? Am J Public Health. 1998;88(6):952-955. 28. National Institute of Health, National Heart, Lung, and Blood Institute. Obesity education initiative. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. 1998. Available at: www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf. Accessed January 3, 2016. 29. Eisenburg ME, Neumark-Sztainer D, Lust KD. Weight-related issues and high-risk sexual behaviors among college students. J Am Coll Health. 2005;54(2):95-101. 30. Averett S, Corman H, Reichman NE. Effects of overweight on risky sexual behavior of adolescent girls. Econ Inq. 2013;51(1):605-619. 31. Cheng YA, Landale NS. Adolescent overweight, social relationships and the transition to first sex: gender and racial variations. Perspect Sex Reprod Health. 2011;43(1):6-15. 32. Shisslak CM, Crago M, Estes LS. The spectrum of eating disturbances. Int J Eat Disord. 1995;18(3):209-219. 33. Leech TG, Johnson Dias J. Risky sexual behavior: a race-specific social consequence of obesity. J Youth Adolesc. 2012;41:41-52. 34. Neumark-Sztainer D, Wall MM, Story M, Perry CL. Correlates of unhealthy weight-control behaviors among adolescents:
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implication for prevention programs. Health Psychol. 2003;22(1): 88-98. Gowers SG, Shore A. Development of weight and shape concerns in the aetiology of eating disorders. Br J Psychiatry. 2001;179:236-242. Leion GR, Fulkerson JA, Perry CL, Keel PK, Klump KL. Three to four year prospective evaluation of personality and behavioral risk factors for later disordered eating in adolescent girls and boys. J Youth Adolesc. 1999;28(2):181-196. Neumark-Sztainer D, Story M, Hannan P, Perry C, Irving L. Weight-related concerns and behaviors among overweight and nonoverweight adolescents. Arch Pediatr Adolesc Med. 2002;156(2):171-178. Thorlton J, Park C, Hughes T. Diet pills, powders, and liquids: Predictors of use by healthy weight females. J Sch Nurs. 2014;30(2):129-135. US Centers for Disease Control and Prevention. Methodology of the youth risk behavior surveillance system—2013. MMWR Morb Mortal Wkly Rep. 2013;62(1):1-20. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 Youth Risk Behavior Survey questionnaire. J Adolesc Health. 2002;31(4):336-342. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174. Strauss R. Childhood obesity and self-esteem. Pediatrics. 2000;105(1):e15-e21. Etcoff N, Orbach S, Scott J, D’Agostino H. The real truth about beauty: a global report. Findings of the global study on women, beauty, and well-being. 2004. Available at: www.campaign forrealbeauty.ca. Accessed June 18, 2014. Kostanski M, Gullone E. Adolescent body dissatisfaction: relationships with self-esteem, anxiety, and depression controlling for body mass. J Child Psychol Psychiatry. 1998;39(2):255-262. Brausch AM, Muehlenkamp JJ. Body image and suicide ideation in adolescents. Body Image. 2007;4:207-212. Hardt J, Bernert S, Matschinger H, et al. Suicidality and its relationship with depression, alcohol disorders and childhood experiences of violence: Results from the ESEMeD study. J Affect Disord. 2015;175:168-174. Ege M, Messias E, Thapa P, Krain L. Adverse childhood experiences and geriatric depression: Results from the 2010 BRFSS. Am J Geriatr Psychiatry. 2015;23(1):110-114. Brausch AM, Guiterrez PM. The role of body image and disordered eating as risk factors for depression and suicidal ideation in adolescents. Suicide Life Threat Behav. 2009; 39(1):58-71. Thatcher WG, Reininger B, Drane JW. Using path analysis to examine adolescent suicide attempts, life satisfaction, and health risk behavior. J Sch Health. 2002;72(2):71-77. Akos P, Levitt D. Promoting healthy body image in middle school. Sch Couns. 2002;6(2):138. Granatino R, Haytko DL. Body image, confidence, and media influence: a study of middle school adolescents. J Appl Bus Res. 2013;29(1):45-50.
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Extreme Weight-Control Behaviors and Suicide Risk Among High School Students EMILY R. JOHNSON, MS, CHESa ROBERT M. WEILER, PhD, MPHb TRACEY E. BARNETT, PhDc LISA N. PEALER, PhDd
ABSTRACT BACKGROUND: Suicide is the third leading cause of death for people ages 15-19. Research has established an association across numerous risk factors and suicide, including depression, substance abuse, bullying victimization, and feelings of alienation. However, the connection between disordered eating as manifested in extreme weight-control behaviors (EWCB), and suicidal thoughts, ideation, and attempts among adolescents is less understood. Given the prevalence of adolescent suicide, this investigation examined associations between EWCB and suicide risk among high school students. METHODS: Data were collected from a convenience sample of 4178 students in grades 9-12 attending 5 public high schools using the Youth Risk Behavior Survey (YRBS) questionnaire. Logistic regressions were used to estimate associations between EWCB and suicide controlling for grade level and race, reported separately by sex. RESULTS: Students who reported seriously considering suicide had higher odds of exhibiting all 3 EWCBs [adjusted odds ratio (AOR)(male) = 3.0 (confidence interval (CI): 1.4, 6.5); AOR(female) = 4.5 (CI: 2.5, 8.3)]. Moreover, students who reported they made plans about suicide were also more likely to exhibit all EWCBs [AOR(male) = 3.7 (CI: 1.7, 7.9); AOR(female) = 4.2 (CI: 2.3, 7.7)]. CONCLUSIONS: EWCBs were significantly associated with suicide risk, furthering the evidence suggesting a link between disordered eating and suicide. Findings demonstrated the need for school health services that address disordered eating in the effort to reduce adolescent suicide. Keywords: suicide; suicidality; weight-control behaviors; unhealthy eating; health risk; adolescents; high school students; teenagers; survey research; Youth Risk Behavior Survey. Citation: Johnson ER, Weiler RM, Barnett TE, Pealer LN. Extreme weight-control behaviors and suicide risk among high school students. J Sch Health. 2016; 86: 281-287. Received on September 29, 2014 Accepted on November 9, 2015
Y
outh suicide is a serious public health problem as more adolescents die from suicide in the United States than from all leading natural causes of death combined.1,2 Resulting in approximately 1600 lives lost annually,3 suicide is currently the third leading cause of death for youth between the ages of 1519. Among females ages 15-19, suicide is the second leading cause of death; it is the third leading cause of death among males between the ages of 15 and 19.2,4 Suicides among youth between the ages of 1524 comprise 12% of all suicide deaths in the United
States1 and these rates reflect a 3-fold increase over the past 45 years.1,5 Risk factors associated with suicide include depression,3,6,7 feelings of hopelessness,3,8,9 physical or chronic illness,5,9 family history of suicidal behavior,3,9 limited social support and social isolation,8,10 poor coping skills,8 alcohol and substance use,10-12 risky sexual behaviors,13,14 and poor body image.4,6,15-17 For example, one study examining a cohort of 1000 adolescent boys and girls found a higher rate of suicidal behaviors in those scoring high
a Doctoral Candidate, ([email protected]fl.edu), Department of Health Education & Behavior, College of Health and Human Performance, University of Florida, PO Box 118210, 1864 Stadium Road, Suite 106K, Gainesville, FL 32611. b Professor and Chair, ([email protected]), Department of Global and Community Health, College of Health and Human Services, George Mason University, 4400 University Drive, MS 5B7, Fairfax, VA 22042. c Assistant Professor, ([email protected]fl.edu), Department of Behavioral Science and Community Health, College of Public Health and Health Professions, University of Florida, PO Box 100175, 1225 Center Drive, Gainesville, FL 32610. dSenior Public Health Consultant, ([email protected]), Hassett Willis, 1100 New York Avenue, NW, Washington, DC 20005.
Address correspondence to: Emily R. Johnson, Doctoral Candidate, ([email protected]fl.edu), Department of Health Education & Behavior, College of Health and Human Performance, University of Florida, PO Box 118210, 1864 Stadium Road, Suite 106K, Gainesville, FL 32611. Partial funding for this study was provided by Purdue Pharma, L.P., Stamford CT (Grant # NED 1022329). Robert M. Weiler, Principal Investigator.
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on the body attitudes test,18 indicative of high body dissatisfaction.19 A growing body of evidence suggests that some individuals may be predisposed to suicidal behaviors and are more likely to engage in suicidal ideation, thoughts, and attempts in response to stressors.20 Among girls, body image and weight-control behaviors appear to be 2 discrete stressors that may trigger a preexisting diathesis for suicide behavior.20-22 Zhang’s Strain Theory of Suicide also explains the role of strain or stressors resulting from psychological suffering23 and posits that unrealistic body image and weight-control behaviors are significantly correlated with suicidal behaviors.16 Furthermore, research has shown that whereas adolescent boys are more likely to die from suicide, girls are more likely to plan and attempt suicide.9,17 Dieting for weight control or weight loss is a commonly reported practice among adolescents24 and weight-control practices could be viewed as either health-promoting or risk-taking behaviors.25 However, extreme weight-control behaviors (EWCB), such as the use of laxatives or diet pills, skipping meals or fasting, and purging are associated with the initiation of risk-taking behaviors, which can lead to serious negative health outcomes.26 In one prospective study, dieting was associated with an 8-fold increase in developing an eating disorder over a 1-year period26 and reports show that approximately 20-25% of ‘‘normal dieters’’ progress to partial or full-syndrome eating disorders.27 Furthermore, preoccupation with weight and unhealthy weightcontrol behaviors can initiate numerous other negative behaviors, including smoking,13 alcohol and drug use,13 risky sexual practices,28-31 and suicide.13 The personal consequences and societal burden resulting from these behaviors are well-known, and as result, have been the focus of numerous school and public health prevention policies, programs, and healthrelated services. Although numerous studies have identified the association of an increased risk for eating disorder symptoms with excessive weight and shape concerns and unhealthy weight-loss behaviors in adolescents,9,26,32-35 research regarding the role of EWCB on suicide has been limited. This study examined the relationship of EWCB and suicidal thoughts, ideation, and attempts among high-school students in the United States. The overall aim of the study was to determine if adolescents who engage in EWCB are at a greater risk for suicide than those not engaging in EWCB. We hypothesized that there would be a significant association between EWCB and suicidal thoughts and actions, and that those who engage in EWCB are at a greater risk for suicide than those who do not engage in EWCB. Moreover, in line with previous research,17,19,36-38 we hypothesized that girls 282 •
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would be more likely to report using weight-control behaviors, and therefore, would be more likely to report engaging in EWCB. Finally, we hypothesized that more girls would report planning and attempting suicide than boys.
METHODS Participants Data were collected during fall 2010 and spring 2011. The convenience sample included 4148 students in grades 9-12 enrolled in 5 public high schools in 5 states (California, Florida, Illinois, New Jersey, and West Virginia). The Youth Risk Behavior Survey (YRBS)39 was used as an anonymous, groupadministered, cross-sectional survey. The schools were selected to obtain a large and diverse group of participants to support the aims of a larger study. The dates and class periods of data collection were arranged to accommodate individual school schedules. Schools received a stipend and a needs assessment report for their participation. Instrumentation Demographic data were assessed using 3 selfreported questions from the YRBS: (1) ‘‘What is your sex?’’ (female/male); (2) ‘‘In what grade are you?’’ (9th/10th/11th/12th); and (3) ‘‘How do you describe yourself (select only 1 response)?’’ (American Indian or Alaska Native/Asian/Black or African American/Hispanic or Latino/Native Hawaiian or Other Pacific Islander/White/Other). Owing to low prevalence, some categories required combining for appropriate statistical analysis; thus, the final categories for race were: Black, Hispanic, White, and other. Weight-control behaviors were assessed using 3 questions from the YRBS: (1) ‘‘During the past 30 days, did you go without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?’’ (yes/no); (2) ‘‘During the past 30 days, did you take diet pills, powders, or liquids without a doctor’s advice to lose weight or keep from gaining weight? (Do not include meal replacement ® products such as Slimfast )’’ (yes/no); and (3) ‘‘During the past 30 days, did you vomit or take laxatives to lose weight or to keep from gaining weight?’’ (yes/no). Endorsing these behaviors (yes response) were used to identify the participant as engaging in that behavior. A composite variable, EWCB, was created by combining the responses for participants who responded ‘‘yes’’ to all 3 questions. Suicide risks behaviors were assessed using 4 questions from the YRBS: (1) ‘‘During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you
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stopped doing some usual activities?’’ (yes/no); (2) ‘‘During the past 12 months, did you ever seriously consider attempting suicide?’’ (yes/no); (3) ‘‘During the past 12 months, did you make a plan about how you would attempt suicide?’’ (yes/no); and (4) ‘‘During the past 12 months, how many times did you actually attempt suicide?’’ (‘0 times,’ ‘1 time,’ ‘2 or 3 times,’ ‘4 or 5 times,’ ‘6 or more times’)?’’ For this analysis, the response options were dichotomized into ‘‘0 times’’ and ‘‘1 or more times’’ with participants who reported 0 times serving as the referent group.10 In a 2000 study conducted by the Centers for Disease Control and Prevention (CDC), the weight control and suicide risk questions demonstrated modest to substantial test-retest reliability39 as measured by the kappa statistic and using the qualitative benchmarks suggested by Landis and Kock.40,41 Kappas for the 3 weight-control questions ranged from 40.1 to 42.1 (moderate reliability). Kappas for the 4 suicide risk questions ranged from 56.4 (moderate reliability) to 74.3 (substantial reliability). Data Analysis Data were analyzed using SAS 9.4 for Microsoft ® Windows . Descriptive summary statistics were generated to examine all variables. Independent logistic regression models were constructed to measure associations between the weight controls behaviors and the suicide risk behaviors (feeling sad or hopeless every day for 2 or more weeks in a row, seriously consider attempting suicide, planning a suicide attempt, and actually attempting suicide). Models were separated and are presented by sex. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated, controlling for grade level and race/ethnicity. Participants who responded ‘‘no’’ to the ‘‘yes/no’’ questions served as the referent group. Alpha ≤ .05 were considered statistically significant.
RESULTS Nearly half of the participants were white (48.4%), 19.2% were black, 14% were Hispanic, and 18.4% were other race/ethnicity. Just over half of the participants were girls (51.7%). Among all participants, 12.7% reported fasting for at least 24 hours in the past 30 days, 5.3% used diet pills, powders, or liquids in the past 30 days, and 5.2% vomited or used laxatives during the past 30 days to keep from gaining weight. Of all participants, 77 (2%) were at risk for all 3 EWCB (Table 1). Girls were more likely to report fasting to lose weight compared with boys (69.9% versus 30.1%; X2 = 68.6, p < .0001) (Table 2). Girls were also more likely to report using diet pills, powders, or liquids (67.0% versus 33.0%, X2 = 18.0, p < .0001). Girls more often reported vomiting or taking laxatives for weight control (71.2% versus 28.8%, Journal of School Health
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Table 1. Participant Demographics and Weight-Control and Suicide Risks (N = 4148) Characteristics
N (%)
Sex Boys 2004 (48.3) Girls 2144 (51.7) Grade 9 1122 (27.1) 10 1142 (27.6) 11 1004 (24.2) 12 874 (21.1) Race Black 794 (19.2) Hispanic 581 (14.0) White 2004 (48.4) Other 764 (18.4) Weight-control behaviors Fast during past 30 days to keep from gaining weight No 3478 (87.3) Yes 505 (12.7) Diet pills during past 30 days to keep from gaining weight No 3772 (94.8) Yes 209 (5.3) Vomit during past 30 days to keep from gaining weight No 3755 (94.8) Yes 206 (5.2) Risk for all 3 weight-control behaviors, calculated No 3866 (98.1) Yes 77 (2.0) Suicide risk behaviors Feelings of hopelessness in past 12 months No 2893 (69.7) Yes 1257 (30.3) Considered suicide in the past 12 months No 3435 (82.8) Yes 715 (17.2) Planned suicide in past 12 months No 3543 (85.5) Yes 603 (14.5) Attempted suicide in the past 12 months No 3547 (85.2) Yes 614 (14.8)
X2 = 29.7, p < .0001). Reporting all 3 disordered eating patterns (EWCB composite) however, showed no differences between girls (58.4%) and boys (41.6%). Grade level was associated with being at risk for all 3 weight-control behaviors, with 39.2% of 9th graders reporting risk, compared with 18.9% of 10th graders, 17.6% of 11th graders, and 24.3% of 12th graders (X2 = 8.2, p < .05). Among all participants, 30.3% reported feelings of hopelessness, 17.2% reported considering suicide, 14.5% planned suicide, and 14.8% had attempted suicide at least once during the past 12 months preceding the administration of the survey (Table 1). Girls were more likely to report feelings of hopelessness in the past 12 months compared with boys (64.1% versus 35.9%; X2 = 109.2, p < .0001). Girls were more likely to have considered suicide in the past 12
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Table 2. Prevalence of Disordered Eating and Suicide Risk Behaviors Variable
Boys N = 2004 (%)
Girls N = 2144 (%)
Disordered eating variables (IV) Went without eating ≥24hours No 1727 (49.9) 1733 (50.1) Yes 151 (30.1) 350 (69.9) Took diet pills, powders, or liquids No 1808 (48.2) 1945 (51.8) Yes 68 (33.0) 138 (67.0) Vomit or took laxatives No 1804 (48.3) 1930 (51.7) Yes 59 (28.8) 146 (71.2) Risk for all 3 weight-control behaviors, calculated No 1820 (47.3) 2025 (52.7) Yes 32 (41.6) 45 (58.4) Suicide risk behaviors (DV) Feelings of hopelessness in past 12 months No 1543 (53.6) 1334 (46.4) Yes 448 (35.9) 799 (64.1) Considered suicide in past 12 months No 1736 (50.9) 1677 (49.1) Yes 257 (36.3) 451 (63.7) Planned suicide in last 12 months No 1762 (50.0) 1759 (50.0) Yes 229 (38.4) 368 (61.6) Attempted suicide in past 12 months No 1702 (48.3) 1825 (51.7) Yes 294 (48.5) 312 (51.5)
Chi-Square
68.6 (p< .0001)
18.0 (p< .0001)
29.7 (p< .0001)
n.s.
109.2 (p< .0001)
49.8 (p< .0001)
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Sad or hopeless every day for 2+ weeks Went without eating ≥24 hours Took diet pills, powders, or liquids Vomit or took laxatives Extreme—did all 3 Seriously considered attempting suicide Went without eating ≥ 24 hours Took diet pills, powders, or liquids Vomit or took laxatives Extreme—did all 3 Made a plan about committing suicide Went without eating ≥24 hours Took diet pills, powders, or liquids Vomit or took laxatives Extreme—did all 3 Attempted suicide Went without eating ≥24 hours Took diet pills, powders, or liquids Vomit or took laxatives Extreme—did all 3
Boys Adjusted + Model OR (CI)
Girls Adjusted + Model OR (CI)
4.0 (2.8-5.6) 3.3 (2.0-5.4) 4.4 (2.6-7.6) 3.4 (1.7-7.0)
3.6 (2.8-4.5) 3.7 (2.5-5.3) 3.8 (2.7-5.5) 5.1 (2.6-10.2)
4.0 (2.8-5.9) 3.1 (1.8-5.3) 4.1 (2.4-7.3) 3.0 (1.4-6.5)
3.6 (2.8-4.6) 2.7 (1.9-3.9) 3.5 (2.5-5.0) 4.5 (2.5-8.3)
4.1 (2.8-6.1) 3.1 (1.8-5.5) 3.0 (1.6-5.6) 3.7 (1.7-7.9)
3.0 (2.3-4.0) 2.8 (1.9-4.0) 3.8 (2.7-5.5) 4.2 (2.3-7.7)
1.6 (1.0-2.4) 1.1 (0.6-2.2) 3.2 (1.8-5.6) 1.9 (0.8-4.3)
2.8 (2.1-3.7) 2.9 (2.0-4.3) 2.8 (1.9-4.1) 4.5 (2.5-8.4)
27.9 (p< .0001)
n.s.
months (63.7% versus 36.3%, X2 = 27.9, p < .0001) and also to have planned suicide in the past 12 months (61.6% versus 38.4%, X2 = 27.9, p < .0001). There were no differences between girls and boys, however, for attempting suicide in the past 12 months (51.5% versus 48.5%, respectively) (Table 2). There was an association between grade level and considering suicide. Specifically, 9th graders reported the highest risk (29.6%), followed by 11th graders (26.6%), then 10th graders (24.3%), and 12th graders (19.5%) (X2 = 8.0, p < .05). Considering suicide in the past 12 months also displayed race/ethnicity differences (X2 = 9.3, p < .05), such that Whites reported the highest risk (47.1%), followed by other races/ethnicities (22.3%), Blacks (17.4%), and Hispanics reporting the lowest risk (13.2%). Planning suicide also was associated with race/ethnicity differences (X2 = 14.9, p < .01) similar to considering suicide; Hispanics reported the lowest (15.8%) and Whites reported the highest (42.6%). There were no race or grade differences for suicide attempts. In models adjusting for grade and race (Table 3), boys and girls who reported feeling sad or hopeless had higher odds of going without eating for more than 24 hours using diet pills, powders, or liquids and vomiting or taking laxatives. Students who reported 284
Table 3. Adjusted Odds Ratios (OR) and 95% Confidence Intervals (CIs) for Reporting Extreme Weight-Control Behaviors by Sex
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feeling sad or hopeless also had higher odds of exhibiting EWCB (all 3 EWCB) [AOR(male) = 3.4 (CI: 1.7, 7.0); AOR(female) = 5.1 (CI: 2.6, 10.2)]. Students who reported seriously considering attempting suicide, as well as reported making a plan about suicide, exhibited higher odds of going without eating for more than 24 hours, using diet pills, powders, or liquids, and vomiting or taking laxatives. Students who reported seriously considering suicide had higher odds of exhibiting EWCBs [AOR(male) = 3.0 (CI: 1.4, 6.5); AOR(female) = 4.5 (CI: 2.5, 8.3)] and students who reported they made plans about suicide were also more likely to exhibit EWCBs [AOR(male) = 3.7 (CI: 1.7, 7.9); AOR(female) = 4.2 (CI: 2.3, 7.7)]. Students who reported attempting suicide were at higher odds of going without eating for more than 24 hours, using diet pills, powders, and liquids, and vomiting or taking laxatives. Moreover, those who reported attempting suicide were also more likely to have exhibited all EWCBs [AOR(male) = 1.9 (CI: 0.8, 4.3); AOR(female) = 4.5 (CI: 2.5, 8.4)].
DISCUSSION According to 2011 national estimates, nearly 8% of high school students self-reported having attempted suicide 1 or more times in the previous 12 months, and of those attempts, 2% resulted in serious injury that required medical care.24 Someone in the United States commits suicide every 13.7 minutes, and for each youth suicide, an estimated 200 youth make a © 2016, American School Health Association
suicide attempt.4 Our study also identified a positive association between each disordered eating variable, as well as the composite EWCB and suicide among adolescents. Research indicates that early adolescence is a critical time for children because it is the period in which they are developing their sense of self-worth.42 Sense of self-worth, as well as self-esteem, can be considered key indicators for mental and emotional health, and can contribute to social success and well-being.42 Adolescence is also a vulnerable time in regards to body image. Satisfaction with physical appearance is an important determinant in sense of self42 and body image, or how you view your body. Your level of comfort with yourself, is developed over time as a result of outside influences, such as media portrayal and messages from other. In one survey that polled 3300 girls and women in 10 countries around the world, more than 90% of girls aged 15 to 17 years wanted to change at least one aspect of their physical appearance, with body weight ranking the highest.43 Whereas girls tend to experience greater discomfort and dissatisfaction with their changing bodies than do boys, a negative body image is prevalent in males as well.44 Although more than two-thirds of all participants that reported practicing any EWCB were girls, information regarding the importance of healthy eating habits and positive body image among all adolescents is crucial. To build feelings of selfworth, body image, and self-esteem, positive messages should be portrayed beginning in early childhood and throughout adolescence. Moreover, our findings support the need to consider body image as a component of self-harm behavior. Researchers have reported that suicidal adolescents report more negative body image, that body dissatisfaction is predictive of suicidal ideation beyond depression and hopelessness, and that suicidal adolescents with a negative body image exhibit higher levels of dissociation.8,44,45 This, along with the association between thoughts of suicide and feelings of hopelessness with the use of all 3 EWCB, demonstrates the need for programs that address these problems, as well as increased awareness and recognition in the health field. It is also important to note the association between suicide, depression, and trauma. Adverse childhood experiences (ACEs), such as early violent episodes in the home, can constitute risk factors for suicide46 and have been found to be associated with a variety of poor outcomes.47 These events can also, in turn, result in adolescent depression and suicidality. It is impossible to know if these ACEs and coinciding depression actually lead to an increased propensity to adolescent obesity, and eventually, patterns of EWCB. However, the link between trauma, depression, and obesity is probable. Journal of School Health
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Limitations Several limitations should be considered when weighing the implications of the current findings. First, the measures used were not designed to measure subclinical conditions or symptoms related to depressive disorders, suicide risk, or disordered eating. Rather the findings of this study are based on the analysis of measures contained in the YRBS which are designed to determine the prevalence of risk factors associated with suicide and problem eating behaviors which can be used to assist in planning, implementing, and evaluating health promotion programs and policies. Relatedly, the YRBS version used in this study did not include other potentially mediating measures such as trauma and other mental health disorders that might have been useful in the explaining the associations between suicide risk and disordered eating. Thus, it would be inappropriate to interpret the findings beyond this purpose. Second, despite the large and diverse sample, the data for this study were collected from a convenience sample, limiting the generalizability of the findings. Thus, future research should consider conducting a replicationsecondary analysis of the 2015 YRBS to determine if the current findings hold. Third, the findings are based on retrospective, self-report, anonymous, groupadministered surveys. Although the survey protocol was constructed to ensure participant anonymity, some participants may have provided inaccurate responses due to the sensitivity of the questions. The findings are also susceptible to other weaknesses of cross-sectional studies which threaten the precision and validity of the findings, namely response bias resulting from poor recall. Conclusions This study is distinct in that it examined 3 different EWCB, separately and combined, with suicide risk factors among boys and girls across a broad range of racial/ethnic groups in a convenience sample of public high-school students. The findings showed that a proportion of both boys and girls in public high schools engaged in unhealthy weight-control behaviors and were thinking about, planning, or considered attempting suicide. Despite variations in prevalence, EWCB appeared to be associated with suicide ideation for both sexes, despite grade and race. As the suicide rate for adolescents continues to increase, it is important that any measured response address the intersection of body image, weight-control behaviors, emotional health, and suicide.
IMPLICATIONS FOR SCHOOL HEALTH To change complex behaviors, such as eating patterns, evidence-based programs and policy interventions in both schools and communities must be
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accompanied by an increase in resources for students, especially those suffering with mental health problems. Our findings support the need for improved access to mental health care workers and counselors, as well as universal programs regarding healthy eating habits and weight-management that can support students of all races/ethnicities in making health-promoting decisions. Furthermore, the early age of onset for these EWCB demonstrate the need for these programs to be introduced to students prior to high school. Programs would be most effective in middle school-aged students who are at a critical age in which body acceptance is being questioned.48-51 Moreover, not only should school programs emphasize the difference between healthy and unhealthy weight management practices, but also they should focus on implementing strategies that help children and youth develop a positive bodyimage, self-appreciation, and positive mental health. School districts may benefit from training teachers and school personnel to identify students engaging in EWCB and/or who may be at risk for suicide. Students may also be more comfortable discussing suicide ideation with teachers and school staff who are advocates for positive youth development. Educating decision makers, including school board members, about the support needed for those students struggling with feelings of hopelessness or suicide ideation is important for adopting effective evidence-based programs. As with many adolescent health issues, ameliorating the complex behaviors, and underlying depressive symptomatology associated with EWCB will require a multicommunity approach. Schools should ensure that health services and professionals are inclusive and affirming of their students’ needs, as well as prepared to provide community resources and support networks to those in need. In addition to traditional schoolbased programs, school-based health clinics (SBHCs), where they exist, provide an excellent setting where health care practitioners could provide evidencedbased, one-on-one brief interventions. SBHCs can also expand their referral network to include community health resources that provide related preventative and treatment services. Besides SBHCs, innovative approaches that maximize other community health resources (such as local health departments, health care systems, insurance providers) should be explored. Similarly, faith-based and youth organizations (such as The Boys and Girls Clubs of America), various parent groups and associations, and family centers, are other viable settings which may provide the structure for delivering effective programs and services. Human Subjects Approval Statement The data collection protocol for this study was approved by the Institutional Review Board at the University of Florida (Protocol #2010-U-0960). 286 •
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