Tracy K. Richmond

School Level Contextual Factors Are Associated With the Weight Status of Adolescent Males and Females

Objective: To determine whether school context influences the BMI of adolescent males and females.

Disordered Weight Control Behaviors in Early Adolescent Boys and Girls of Color: An Under-Recognized Factor in the Epidemic of Childhood Overweight

OBJECTIVES Ethnic disparities in childhood overweight are well-documented. In addition, disordered weight control behaviors (DWCB) have been linked to overweight and weight gain in multiple ways, but little is known about DWCB in youth of color, especially boys. We examined the distribution and determinants of ethnic and gender disparities in DWCB in early adolescents. METHODS In fall 2005, 47 Massachusetts middle schools participating in the Healthy Choices overweight prevention study administered a self-report baseline survey assessing student sociodemographics, height, weight, and DWCB (vomiting or use of laxatives or diet pills in the past month to control weight). Data from 16,978 girls and boys were used in multivariate logistic regression models to estimate the odds of DWCB in youth of color compared with their white peers, controlling for individual- and school-level factors. RESULTS Among white youth, 2.7% of girls and 2.3% of boys reported DWCB. The odds of DWCB were elevated 2-10 times in most ethnic groups relative to whites. Disparities were attenuated but persisted after controlling for multiple individual- and school-level factors. CONCLUSIONS Ethnic disparities in DWCB must be considered in efforts to address the epidemic of childhood overweight.

Food Insecurity and Increased BMI in Young Adult Women

Food insecurity has been associated with weight status in children and adults although results have been mixed. We aimed to identify whether food insecurity was associated with BMI in young adults and whether this association differed by gender and was modified by food stamp use and the presence of children in the home. Cross‐sectional data from wave 4 (2007–2008) of the National Longitudinal Study of Adolescent Health were analyzed. Multiple linear regression was used to investigate the association between food insecurity and BMI in gender stratified models of young adult women (n = 7,116) and men (n = 6,604) controlling for age, race/ethnicity, income, education, physical activity, smoking, alcohol use, the presence of children in the home, and food stamp use in young adulthood and/or adolescence. Food insecurity was more common in young adult women (14%) than young adult men (9%). After controlling for a variety of individual variables, food insecure women had a BMI that was on average 0.9 kg/m2 units higher than women who were food secure. This difference in BMI persisted after controlling for recent or past food stamp use and was not different among women with or without children in the household. No relationship was found between food insecurity and BMI in young adult men. Providers should inquire about food insecurity, especially when treating obesity, and policy initiatives should address the role of access to healthy food in those facing food insecurity.

Helpful or harmful? Prospective association between weight misperception and weight gain among overweight and obese adolescents and young adults

Background/Objective:Weight misperception is common among adolescents with obesity, but it is not known whether weight perception is related to future weight gain. The objective of the study was to examine the prospective association between accurate weight perception versus weight misperception and weight change among youth who are overweight or obese.Subjects/Methods:Using a subsample of The National Longitudinal Study of Adolescent to Adult Health Wave II cohort, we used linear regression modeling (adjusted for age, baseline body mass index (BMI), parental education, household percent federal poverty level, depression, race and ethnicity) to examine the prospective association between weight misperception (that is, perceiving oneself to be under or normal weight) among 2738 overweight and obese youth and subsequent BMI change from Wave II (1996) to Wave IV (2008–2009). Mean age at baseline (Wave II) was 15.9 (0.1).Results:Fifty-seven percent of males and 80% of females accurately perceived themselves as overweight. In fully adjusted models, weight misperception was associated with less BMI gain among youth who were overweight and obese. Specifically, youth who perceived themselves to be at a healthy weight had lower BMI gains (males: β= −1.43, 95% confidence interval (CI)=(−2.26, −0.60), P=0.001; females: β= −1.35, 95% CI=(−2.59, −0.11), P=0.035) from Wave II to IV relative to those who accurately perceived themselves as overweight or obese.Conclusions:Contrary to commonly held assumptions, weight misperception among a non-clinical sample of youth who were overweight or obese predicted lower future weight gain. Efficacy of efforts to correct weight misperception should be rigorously examined to assess for both intended and unintended consequences.

The treatment of adolescent depression in the era of the black box warning

Purpose of review This paper reviews the epidemiology and sequelae of adolescent depression, recent studies of antidepressants and psychotherapeutic modalities for treatment of adolescent depression, and the black box warning from the United States Food and Drug Administration regarding the use of antidepressants in adolescents. Recent findings Over the past 4 years, four major randomized placebo-controlled trials of selective serotonin reuptake inhibitors in adolescents have been published. Although each of these published studies concluded that the drug under study was efficacious, the United States Food and Drug Administration and others have offered words of caution. Over the past 2 years, there has been increasing concern that antidepressants may increase suicidal thinking and behavior (not completed suicide) in depressed adolescents. The United States Food and Drug Administration has issued a black box warning asking providers to use caution when prescribing antidepressants in children under the age of 18. Summary Adolescent depression is common, socially and economically costly, and a potentially lethal disease. Recent studies of antidepressant use in adolescents have demonstrated variable efficacy and an increased risk of adverse events, including suicidality. The evidence is greatest to support the efficacy of fluoxetine, and thus it remains the only selective serotonin reuptake inhibitor approved by the United States Food and Drug Administration for the treatment of depression in children and adolescents. Psychotherapy is strongly encouraged in any patient for whom medication is prescribed. The risk of adverse events associated with antidepressant use requires caution when these medications are prescribed to adolescents. In an adolescent with depression, however, there is an inherent and greater risk to doing nothing.

Using Cross-Classified Multilevel Models to Disentangle School and Neighborhood Effects: An Example Focusing on Smoking Behaviors among Adolescents in the United States

BACKGROUND Despite much interest in understanding the influence of contexts on health, most research has focused on one context at a time, ignoring the reality that individuals have simultaneous memberships in multiple settings. METHOD Using the example of smoking behavior among adolescents in the National Longitudinal Study of Adolescent Health, we applied cross-classified multilevel modeling (CCMM) to examine fixed and random effects for schools and neighborhoods. We compared the CCMM results with those obtained from a traditional multilevel model (MLM) focused on either the school and neighborhood separately. RESULTS In the MLMs, 5.2% of the variation in smoking was due to differences between neighborhoods (when schools were ignored) and 6.3% of the variation in smoking was due to differences between schools (when neighborhoods were ignored). However in the CCMM examining neighborhood and school variation simultaneously, the neighborhood-level variation was reduced to 0.4%. CONCLUSION Results suggest that using MLM, instead of CCMM, could lead to overestimating the importance of certain contexts and could ultimately lead to targeting interventions or policies to the wrong settings.

Sexual Orientation and Bias in Self‐Reported BMI

Our objective was to determine if sexual orientation groups differ in accuracy of BMI (kg/m2) calculated from self‐reported height and weight and if weight status modifies possible differences. Using gender‐stratified multiple linear regression to analyze Wave III of the National Longitudinal Study of Adolescent Health (n = 12,197), we examined the association of sexual orientation with BMI calculated from self‐reported height and weight (self‐reported BMI), controlling for BMI calculated from objectively measured height and weight (objectively measured BMI) as well as demographic, health, and behavioral variables. We tested for effect modification of the relationship between sexual orientation and self‐reported BMI by objectively measured BMI. The population underestimated their BMI (females: β = 0.87, P < 0.001; males = 0.86, P < 0.001). Sexual orientation groups differed little in their accuracy of reporting; only gay males had significant underreporting (β = −0.37, P = 0.038) relative to their heterosexual peers. We found no evidence of effect modification of the relationship of sexual orientation and self‐reported BMI by objectively measured BMI. With the exception of gay males, sexual orientation groups are consistent in their underreporting of BMI thus providing confidence in most comparisons of weight status based on self‐report. Self‐reporting of weight and height by gay males may exaggerate the differences in BMI between gay and heterosexual males.

Disentangling the relative influence of schools and neighborhoods on adolescents’ risk for depressive symptoms

OBJECTIVES Although schools and neighborhoods influence health, little is known about their relative importance, or the influence of one context after the influence of the other has been taken into account. We simultaneously examined the influence of each setting on depression among adolescents. METHODS Analyzing data from wave 1 (1994-1995) of the National Longitudinal Study of Adolescent Health, we used cross-classified multilevel modeling to examine between-level variation and individual-, school-, and neighborhood-level predictors of adolescent depressive symptoms. Also, we compared the results of our cross-classified multilevel models (CCMMs) with those of a multilevel model wherein either school or neighborhood was excluded. RESULTS In CCMMs, the school-level random effect was significant and more than 3 times the neighborhood-level random effect, even after individual-level characteristics had been taken into account. Individual-level indicators (e.g., race/ethnicity, socioeconomic status) were associated with depressive symptoms, but there was no association with either school- or neighborhood-level fixed effects. The between-level variance in depressive symptoms was driven largely by schools as opposed to neighborhoods. CONCLUSIONS Schools appear to be more salient than neighborhoods in explaining variation in depressive symptoms. Future work incorporating cross-classified multilevel modeling is needed to understand the relative effects of schools and neighborhoods.

Sexual Orientation Disparities in BMI among US Adolescents and Young Adults in Three Race/Ethnicity Groups

Obesity is a key public health issue for US youth. Previous research with primarily white samples of youth has indicated that sexual minority females have higher body mass index (BMI) and sexual minority males have lower BMI than their same-gender heterosexual counterparts, with sexual orientation differences in males increasing across adolescence. This research explored whether gender and sexual orientation differences in BMI exist in nonwhite racial/ethnic groups. Using data from Waves I–IV (1995–2009) of the US National Longitudinal Study of Adolescent Health (N = 13,306, ages 11–34 years), we examined associations between sexual orientation and BMI (kg/m2) over time, using longitudinal linear regression models, stratified by gender and race/ethnicity. Data were analyzed in 2013. Among males, heterosexual individuals showed greater one-year BMI gains than gay males across all race/ethnicity groups. Among females, white and Latina bisexual individuals had higher BMI than same-race/ethnicity heterosexual individuals regardless of age; there were no sexual orientation differences in black/African Americans. Sexual orientation disparities in BMI are a public health concern across race/ethnicity groups. Interventions addressing unhealthy weight gain in youth must be relevant for all sexual orientations and race/ethnicities.

Weight misperception among young adults with overweight/obesity associated with disordered eating behaviors.

OBJECTIVE The purpose of this study was to examine the cross-sectional association between weight misperception among young adults with overweight/obesity and disordered eating behaviors. METHOD In a subsample of young adults with overweight or obesity participating in Wave III (2001-2002) of The National Longitudinal Study of Adolescent to Adult Health (n = 5,184), we examined the cross-sectional association between weight under-perception (i.e., perceiving oneself to be at a healthy body weight or underweight) and disordered eating (fasting/meal skipping for weight control, purging/pills for weight control, overeating/loss of control eating, and use of performance-enhancing products/substances). RESULTS About 20% of young adult females under-perceived their weight compared to 48% of males. Individuals who misperceived their weight as healthy were significantly less likely to report fasting/meal skipping (Females: OR: 0.25, 95% CI: 0.14-0.43; Males: OR: 0.31, 95% CI: 0.20-0.48) and vomiting or taking diet pills/laxatives/diuretics (Females: OR: 0.10, 95% CI: 0.04-0.25; Males: OR: 0.10, 95% CI: 0.04-0.25) for weight control. Among females, those who misperceived their weight status as healthy were also less likely to report overeating or loss of control eating (OR: 0.41, 95% CI: 0.24-0.71). Greater use of performance-enhancing products/substances was seen among males who under-perceived their weight as healthy (OR: 2.06, 95% CI: 1.57-2.72) and among both females (OR: 2.29, 95% CI: 1.40-20.0) and males (OR: 2.27, 95% CI: 1.13-4.55) who perceived themselves to be underweight. DISCUSSION Weight under-perception among young adults with overweight/obesity may convey some benefit related to disordered eating behaviors, but could be a risk factor for the use of performance-enhancing products/substances.