Our primary aim of this article was to highlight the vulnerability of adolescents with extreme obesity. Accordingly, comparisons were made between HSS with extreme obesity and those of healthy weight, the standard to which health care providers strive. This is consistent with the “extreme group approach” (ie, comparing group of interest to another group that is disparate on a key variable; in this case, weight) that is typically seen in preliminary studies when little is known on a specific subpopulation. This approach allows for detection of general trends that otherwise might be obscured with the inclusion of a full range of data (eg, overweight and less obese youth).32
Documenting the prevalence of engagement in high-risk behaviors for this already vulnerable subpopulation of adolescents is not only timely but also imperative, especially given health care providers' conundrum of how best to intervene when such youth are under their care.33,34
Unfortunately, the weight loss intervention literature (eg, behavioral35–37
) has not progressed sufficiently, and thus, the vast majority of today's youth with extreme obesity will carry their excess weight and associated medical and psychosocial burden into adulthood.12
In addition, as bariatric surgery emerges as a potential and viable treatment option for this age and weight status group40–42
it is critical to establish a most comprehensive picture of the health and mental health needs of this patient population.
These are the first published data characterizing the risk-taking behaviors of HSS with extreme obesity in the United States. The results reveal that there may be reason for concern given that HSS with extreme obesity report similar, and in some cases, even more dangerous engagement in risk-taking behaviors compared with their healthy weight peers. One of the strengths of the present study is that the data were derived from a large, nationally representative data set for which method reliability is well established.43
The YRBS data set provided a large sample of adolescent HSS with extreme obesity from which descriptive data could be accurately presented and stratified, an important consideration given the significant differences in prevalence of risk-taking behaviors between male students and female students.44
In addition, use of this data resource minimized the potential for selection bias, which characterizes most existing data on adolescents with extreme obesity who often are identified for research participation while seeking treatment for weight loss and/or obesity-related comorbidities. The use of a comparison group of healthy weight peers also allowed for meaningful comparisons. Finally, the YRBS allowed consideration of a relatively broad spectrum of high-risk behaviors relevant to the priority areas outlined by Healthy People 2010.45
This is important given research that reveals that engagement in multiple risk behaviors may result in heightened overall risk.46
Obese adolescents are more likely to be socially isolated and peripheral to social networks than are healthy weight peers.18,47
Arguably, adolescents with extreme obesity may be even less fully engaged in age-salient contexts (school, work, peers, romantic relations), and therefore less likely to be exposed to or engage in what might be considered normative high-risk behaviors. With few exceptions, the present findings challenge these assumptions, which indicates that regardless of any social impairment, HSS with extreme obesity engage in high-risk behaviors at comparable, if not higher, rates than healthy weight peers. For instance, the majority of alcohol/tobacco/other drug use behaviors were similar among extremely obese and healthy weight HSS, regardless of whether the behaviors related to age at initiation, current use, or abuse (eg, 5 or more alcoholic drinks in a row), with the exception of cigarette, cocaine, and steroid use. Although female HSS with extreme obesity were less likely to report ever having sex relative to healthy weight female students, HSS with extreme obesity were not at any lower odds of engaging in other sexual behaviors that might be considered high-risk, including first sexual intercourse before age13, sexual intercourse with 4 or more partners during one's lifetime, not using a condom during the last sexual encounter, and rate of testing for HIV. Finally, HSS with extreme obesity were similar to healthy weight peers in their serious consideration of attempting suicide (ie, suicidal ideation), development of a suicide plan, and suicide attempts. Taken together, these results suggest that excess weight does not “protect” HSS from engagement in what might be considered somewhat normative adolescent risk-taking behaviors.
When group (ie, extreme obesity versus healthy weight) differences in high-risk behaviors were detected, the present data indicate HSS with extreme obesity may actually be at heightened risk. For instance, both male and female HSS with extreme obesity reported greater odds of ever trying cigarette smoking compared with gender-specific healthy weight peers, with female students also more likely to have smoked cigarettes and used smokeless tobacco in the past 30 days and male students more likely to have smoked a whole cigarette before the age of 13. Obese adolescents are already at greater risk for the development of additional chronic health conditions,12,48–54
the likes of which may be exacerbated by cigarette smoking, resulting in compound health risk.51
In addition, smoking has been identified as a “gateway” drug that may predispose adolescents (especially female students) to engage in illicit drug use.55
Given these findings, HSS with extreme obesity may warrant tailored nicotine prevention and intervention programs.
Although female HSS with extreme obesity may be less likely to report ever having sexual intercourse, when they do, it may be unduly influenced by substance use. Forty-two percent of female HSS with extreme obesity reported using alcohol or drugs before their last sexual encounter, a fourfold greater likelihood than their healthy weight female peers. These results are concerning given data that reveal drinking and drug use have been found to not only influence adolescents' decisions to engage in sexual activity, but also affect adolescents' decisions to “do more” sexually than they had planned and to have unprotected sex.56
These data highlight that, at least among female HSS, extreme obesity may indicate a greater likelihood of sexual risk-taking, alerting health care providers to conduct a thorough assessment of sexual history and behaviors and provision of appropriate counseling and recommendations regarding healthy sexual behavior.
There are several study limitations worth noting. First, whereas the YRBS database provides reliable data on HSS behavior, adolescent weight and height were self-reported. BMI values on the basis of adolescent self-report of height and weight have been shown to be highly correlated with data on the basis of measured height and weight (r
= 0.89; mean difference, 2.6 kg/m2
although adolescent self-report likely results in an underestimation of weight and an overestimation of height. In addition, BMI scores > 55 were considered “biologically implausible values” and not included in the public-release data set. Although it is understandably necessary to set parameters to exclude implausible data, a BMI > 55 is not only plausible but increasingly common in adolescents as indicated by mean and SD values of BMI for the growing number of adolescents pursuing weight loss surgery.58
Thus, the present study was limited in its ability to characterize the most upper extremes of obesity. Replication of these findings will be important, and includes both measured height/weight and the full spectrum of BMI. Second, YRBS data are cross-sectional in design and, accordingly, causality cannot be inferred. Finally, YRBS is limited to adolescents who attend high school and is therefore not fully representative of this age group.
Comprehensive and longitudinal studies will be critical to ascertain any temporal sequence between obesity development and risk-taking behaviors in adolescence. In addition, more complex pathways that link obesity and risk-taking behaviors need to be considered, such as those involving pubertal timing and psychological dysregulation. For example, higher BMIs have been associated with earlier pubertal onset among female students59,60
and later pubertal onset for male students.61
These gender-specific trajectories on the basis of pubertal timing, regardless of weight, have been associated with negative psychosocial62
and behavioral outcomes such as alcohol/tobacco/other drug use,63–65
sexual initiation, and engagement in delinquent behaviors.66
Psychological dysregulation (ie, one's ability to modulate affect, cognition, and behavior) is also believed to increase an adolescent's risk of substance use, high-risk sexual behavior, and suicidal behaviors.67
Finally, although we controlled for race/ethnicity and age in this study, future research in which differential engagement in risk behaviors is explored on the basis of these factors may reveal noteworthy findings.