Adolescent obesity as well as teen suicide are leading public health challenges. While adolescent suicide has many known risk factors,3
should adolescent excess weight status and further, recognition of that excess weight by the adolescent, be added to this list? The present study advances the adolescent health literature in several unique ways. First, these results are based on a large nationally representative sample of high school students both in terms of demographics as well as prevalence of excess weight status. Second, for the first time in the adolescent obesity/suicide literature, adolescents who were extremely obese (BMI≥ 99th
percentile) were deliberately differentiated from those who were relatively less obese (BMI 95th
percentile), or overweight (BMI 85th
percentile). Previous studies in this area, the majority of which also utilized YRBS data, did not identify the extreme sub-group13-16
, did not differentiate those who were obese (BMI ≥ 95th
percentile) from those who were overweight (BMI 85th
or did not consider the entire excess weight spectrum.22
Finally, recognizing that the previous adolescent suicide literature suggests an adolescent’s perception of weight (e.g., overweight, underweight) may play an important role in understanding suicidal risks, we examined accuracy of weight perception in a manner recently presented by Edwards and colleagues17
utilizing YRBS 2007 data (e.g., whether an adolescent who carries excess weight reports they are “overweight”), given its relative simplicity and potential utility for use in clinical settings.
Our initial analyses examined the most basic questions: are actual excess weight status and suicidal behaviors linked in adolescence? And, what is the prevalence of weight perception accuracy in adolescents with varying levels of excess weight? This first step revealed that, relative to youth of healthy weight, being obese or extremely obese (but not overweight) was associated with significantly greater risk for adolescent engagement in suicidal ideation, though excess weight did not increase the odds of suicide attempts during the same time period. Thus, being obese or when it has progressed to an extreme level is associated with heightened risk of one suicidal behavior but not the other, with risk of attempting suicide no greater than “normative” adolescent risk. This was arguably unexpected, although existing literature demonstrates a suicide risk factor can influence one adolescent suicidal behavior (e.g., attempt) and not the other (e.g., ideation).23
these multi-year (2007, 2009) YRBS data document that weight misperception was remarkably common in adolescents with excess weight. Interestingly there was evidence of increasing weight perception accuracy as the degree of excess weight increased. In fact, 4 out of 5 adolescents with extreme obesity acknowledged their “overweight” status.
When actual weight status was placed in the context of whether or not an adolescent with excess weight perceived him/herself to be overweight, findings became less straightforward. With regard to suicidal ideation, an overweight, obese, or extremely obese adolescent (regardless of race, gender, age, or whether they acknowledged feelings of sadness/hopelessness) who understood they were overweight, was at significantly greater risk of reporting suicidal ideation than adolescents of healthy weight (who also accurately perceived their weight). Thus, our findings suggest that for all excess weight status groups represented in the present analyses (e.g., overweight, obese, extremely obese), it is not actual BMI that is key, but rather, weight perception accuracy that increases risk of adolescent suicidal ideation. In contrast, non-recognition of overweight status for an adolescent with of any level of excess weight indicated more “normative” (e.g., similar to healthy weight/accurate youth) suicidal ideation risk. Perhaps then, it is the subgroup of adolescents who both carry excess weight and acknowledge their overweight status who perceive their weight as particularly burdensome. Indeed, a recent study from a clinically referred sample of younger school-age obese children (BMI ≥ 95th
percentile; ages 5-11 years) found obese youth who did not perceive themselves as overweight self-reported less impairment in HRQOL as compared to those who understood they were overweight.24
Like suicidal ideation, findings regarding suicide attempts varied based on actual weight/weight perception accuracy, but also race/ethnicity. Two clear patterns emerged relative to the respective healthy weight/accurate comparators of similar race/ethnicity. For White youth, excess weight status/accuracy had no impact on the odds of reporting a suicide attempt. However, extreme obesity was associated with greater risk of suicide attempts for Hispanic youth only and irrespective of weight perception accuracy. While in general, a disproportionately higher prevalence of suicidal behaviors have been reported for Hispanic youth relative to White and Black youth,25
no associations with obese weight status (BMI ≥ 95th
percentile) have yet to be identified.13,16
To our knowledge, these are the first analyses in the literature that isolate adolescents with extreme obesity within race/ethnic groups, revealing a specific weight group engaging in a less prevalent but more lethal suicidal behavior (actual attempt). Given there were no additional discernible patterns to the suicide attempt data, a clear area for future research is the examination of the role of excess weight status and weight perception accuracy within race/ethnicity that considers additional factors beyond those in the present analyses. Echoing the assertion of previous researchers,16,26
suicidal behavior risk factors, and risk of attempts in particular, may be culture-specific, with prevention efforts needing to be tailored accordingly.
The present findings are both important and clinically relevant. Adolescents who are overweight or obese comprise a considerable proportion of today’s youth, with those who are extremely obese growing in numbers. Furthermore, adolescents who are obese will likely remain obese, carrying disease burden and risk into young adulthood.27
In addition to more universal prevention efforts to decrease adolescent suicidality (e.g., public education, screening programs, education of physicians, restriction of access to lethal means), adolescents with excess weight may benefit from routine screening for suicidal ideation.28
Furthermore, in this context, assessing an adolescent’s perception of whether they are overweight (e.g., “how would you describe your weight?”) may provide critical additional information. This may prove especially relevant to the clinical population of adolescents who consider and/or progress to undergoing bariatric surgery, given findings from the adult bariatric literature. However, it is important to recognize that while a history of suicide ideation in adolescents is known to predict subsequent ideation, a history of not acting
on suicidal ideation (e.g., no attempt) is predictive of continuing not to do so.29
Only a history of progression to an attempt is associated with subsequent risk of a nonfatal or fatal suicide attempt in adolescents.3,29
With the adolescent bariatric surgery outcome literature in its infancy, controlled prospective long-term outcome studies with close monitoring of suicidal behaviors as well as other known risk factors for completed suicides (e.g., previous nonfatal attempts, depression, substance use, family history of suicide, childhood trauma, impulsivity, history of self-harm) are critical.
The present findings must be interpreted within the context of several limitations, with consequent directions for future research. First, YRBS adolescent weight and height (i.e., BMI) were self-reported. Previous work has shown YRBS self-report methodology to be highly correlated with measured weight and height values21
. However, given noted trends that adolescents may underestimate weight and overestimate height, the present data may reflect an underestimation of true BMI and the extent of excess weight in the YRBS sample. Arguably, the present study may also represent an underestimation in weight misperception as well, given weight perception accuracy increased as excess weight status increased. Interestingly however, extant research would suggest that a child or adolescent who carries excess weight does not base their self-perception of their weight status (“Am I overweight or not?”) on just their knowledge (or lack thereof) of their actual height/weight or BMI. Rather, overweight perception accuracy in youth has been shown to be associated with a number of individual and contextual factors including the psychosocial impact of their weight (e.g., weight-related quality of life)24
as well as their social environment. For example, overweight and obese youth are more likely to misperceive their weight status if they have parents or school classmates who are also overweight.31
Second, the YRBS survey was developed with the specific purpose of monitoring epidemiological trends of a broad array of adolescent health and health-risk behaviors, including the extent of suicidality as public health problem for the Centers for Disease Control and Prevention. We recognize single item criterion measures of suicidality, even with established validity18
, are not full clinical assessments of these behaviors. Furthermore, these data characterize only nonfatal suicidal behaviors and do not reflect the role of weight status in completed suicides in adolescents. Thus, comparison to the findings in the adult obesity literature proves challenging, as with few exceptions12,32,33
, those investigating adults have focused on completed suicide as an outcome34-37
, versus the suicidal risk behaviors that precede the fatal event. Third, the YRBS also lacks an indicator of socioeconomic status (SES), a potential confound given suggested links between SES or proxy variables (e.g., parental education) with obesity prevalence in youth38
and weight status misperception39
in adults. Finally, YRBS data is cross-sectional in design and, accordingly, causality cannot be inferred.
We recognize there are a number of additional avenues worthy of further exploration, including weight misperception as it relates to adolescent suicidal behaviors for youth who do not
carry excess weight. For example, in the present data, adolescents who were of a healthy weight yet who misperceived their weight status (either underweight or overweight) were at greater risk of reporting suicidal ideation, and for White and Black adolescents, greater attempts than their healthy weight counterparts who perceived their weight accurately. Further, we did not include examination of the additional weight category of underweight adolescents (BMI < 5th
percentile). Certainly our reported findings and those of others13
highlight weight perception accuracy as critical in understanding adolescent suicide behavior risks. The goals of the present study were deliberately simple in their focus on adolescents with excess weight.
As is evident, not all adolescents of excess weight status or even those at an extreme level will consider or attempt suicide, nor should any adolescent, independent of demographic background or weight status/accuracy, be exempt from monitoring or concern. Adolescent risk pathways for suicidal behaviors will only be understood with the testing of comprehensive adolescent models (e.g., previous nonfatal attempts, depression, peer victimization, family history of suicide, peer suicidal behaviors, impulsivity, substance use, childhood trauma) and with assessments that are more clinically driven (vs. public health surveillance) and utilize prospective designs. Based on the present findings, these future studies would also benefit from use of the actual measurement of height and weight (e.g., weight status), the categorization of the entire excess weight spectrum (e.g., extreme obesity), and the adolescent’s weight perception accuracy when they carry excess weight.