Abstract

The objective of this article is to identify the prevalence and evaluate the factors associated with extreme weight loss behaviors among adolescents of Northeastern Brazil. Cross-sectional study with 2,439 adolescents from Sample 2 (2015) of the National School-based Health Survey. Extreme weight loss behaviors, such as self-induced vomiting, laxative use and use of medicines or formulas (outcome) and independent variables were evaluated using a self-administered electronic questionnaire. The statistical analysis was performed following a hierarchical conceptual model. The prevalence of extreme weight loss behaviors in the sample was 12.1%. Among the factors that showed significant association with the outcome, we emphasize the administration model of the private school (PR = 0.62; CI = 0.46-0.84), bullying related to body appearance and for other reasons (PR = 1.62; CI = 1.19-2.20), forced sexual intercourse (PR = 2.65; CI = 1.90-3.69), insomnia (PR = 1.84; CI = 1.43-2.37), and be perceived as fat or very fat (PR = 1.90; CI = 1.50-2.42). Moderate prevalence of extreme weight loss behaviors was identified among adolescents. Socioeconomic factors, exposure to violence, mental health, and body image were associated with the adoption of these behaviors.

Key words:
Purgative behavior; Weight loss; Induced vomiting; Laxatives; Adolescent

Resumo

O objetivo deste artigo é identificar a prevalência e avaliar os fatores associados aos comportamentos extremos para perda de peso em adolescentes do Nordeste brasileiro. Estudo transversal com 2.439 adolescentes da Amostra 2 (2015) da Pesquisa Nacional de Saúde do Escolar. Os comportamentos extremos para perda de peso (desfecho) e as variáveis independentes foram avaliadas por meio de um questionário eletrônico autoaplicável. A análise estatística foi realizada seguindo um modelo conceitual hierárquico. A prevalência de comportamentos extremos para perda de peso na amostra foi de 12,1%. Entre os fatores que mostraram associação significativa com o desfecho, destacam-se a situação administrativa da escola privada (RP = 0,62; IC = 0,46-0,84), ser vítima bullying relacionado à aparência corporal e pelos demais motivos (RP = 1,62; IC = 1,19-2,20), ser forçado a ter relação sexual (RP = 2,65; IC = 1,90-3,69), ter insônia (RP = 1,84; IC = 1,43-2,37) e se autoperceber como gordo ou muito gordo (RP = 1,90; IC = 1,50-2,42). Prevalência moderada de comportamentos extremos para perda de peso foi identificada entre os adolescentes. Os fatores socioeconômicos, de exposição à violência, de saúde mental e da imagem corporal se associaram à adoção de tais comportamentos.

Palavras-chave:
Comportamento purgativo; Perda de peso; Vômito induzido; Laxantes; Adolescente

Introduction

Adolescence is the period of life in which intense physical, psychological, and behavioral changes occur¹1 World Health Organization (WHO). Coming of age: adolescent health. Geneva: WHO; 2019.. Besides dealing with the changes already expected for that phase, adolescents are faced with beauty standards and extreme appreciation of appearance, resulting in unreal internalization and consequent increase in insecurity, anxiety, and body dissatisfaction²2 Vitolo MR, Bortolini GA, Horta RL. Prevalência de compulsão alimentar entre universitárias de diferentes áreas de estudo. Rev Psiquiatr RS 2005; 28(1):20-26..

The search for a body pattern socially accepted can lead the adolescent to adopt extreme weight loss behaviors (EWLB), such as restrictive diet and fasting, use of food substitutes, smoking more cigarettes, use of laxatives, diuretics, and medications as well as induction of vomiting³3 Neumark-Sztainer D, Wall M, Story M, Standish AR. Dieting and unhealthy weight control behaviors during adolescence: associations with 10-year changes in body mass index. J Adolesc Health 2012; 50(1):80-86.

4 Ferreira CS, Andrade FB. Tendência de atitudes extremas em relação ao peso em adolescentes e sua relação com suporte familiar e imagem corporal. Cien Saude Colet 2020; 25(5):1599-1606.

5 Vale D, Dantas RF, Amorim GKD, Lyra CO, Oliveira AGRC. Determinantes sociais de comportamentos alimentares desordenados entre adolescentes brasileiros. Rev Debat Psiquiat 2021; 11:1-22.^-66 Santana ML, Assis AM, Silva RC, Raich RM, Machado ME, Pinto EJ, Moraes LT, Ribeiro HC. Risk factors for adopting extreme weight-control behaviors among public school adolescents in Salvador, Brazil: a case-control study. J Am Coll Nutr 2016; 35(2):113-117..

The assessment of such behaviors varies between studies. In Brazil, Leme et al.⁷7 Leme AC, Philippi ST, Thompson D, Nicklas T, Baranowski T. ''Healthy habits, healthy girls - Brazil'': an obesity prevention program with added focus on eating disorders. Eat Weight Disord 2019; 24:107-119., in a cluster randomized controlled study, identified in adolescents three categories to classify weight control behaviors, including healthy ones (exercising, eating more fruits and vegetables, eating fewer fatty foods, eating fewer sweets), unhealthy ones (skipping meals, eating little and fast), extreme unhealthy behaviors (using diuretics and smoking) and, lastly, other weight control behaviors (medicines, meal substitutes). In subsequent studies with Brazilian adolescents, this classification was changed to a broader concept, already established, grouping all categories of unhealthy weight control behaviors. For example, Dunker & Claudino⁸8 Dunker KL, Claudino AM. Validity and reliability of the Brazilian version of the weight control behaviors scale. J Pediatr 2017; 189:143-148. adopted the definition of New Moves Project.⁹9 Neumark-Sztainer DR, Friend SE, Flattum CF, Hannan PJ, Story MT, Bauer KW, Feldman SB, Petrich CA. New moves - preventing weight - related problems in adolescent girls: a group-randomized study. Am J Prev Med 2010; 39(5):421-432. and Ferreira et al.¹⁰10 Ferreira JES, Veiga GV. Confiabilidade (teste-reteste) de um questionário simplificado para avaliar comportamentos de risco para transtornos alimentares em adolescentes. Rev Bras Epidemiol 2008; 11(3):393-401. applied an adaptation of the Hay scale¹¹11 Hay P H. The epidemiology of eating disorder behaviors: an Australian community-based survey. J Eat Disord 1998; 23(4):371-382..

The involvement of adolescents with EWLB is a serious concern with clinical relevance, because of its contribution to the etiology of eating disorders and obesity, in addition to adverse physiological effects, such as esophagitis, gastric rupture, and functional gastrointestinal disorders¹²12 Golden NH, Schneider M, Wood C, Committee on Nutrition, Committee on Adolescence, Section on Obesity. Preventing obesity and eating disorders in adolescents. Pediatrics 2016; 138(3):e20161649.^,1313 Herzog W, Deter HC, Fiehn W, Petzold E. Medical findings and predictors of long-term physical outcome in anorexia nervosa: a prospective, 12-year follow-up study. Psychol Med 1997; 27(2):269-279..

In recent decades, there has been a worrying prevalence of EWLB among adolescents in both developed countries (6.2% to 12%)¹⁴14 Kim Y, Austin SB, Subramanian SV, Thomas JJ, Eddy KT, Franko DL, Rodgers RF, Kawachi I. Risk factors for disordered weight control behaviors among Korean adolescents: multilevel analysis of the Korea Youth Risk Behavior Survey. Int J Eat Disord 2018; 51(2):124-138.^,1515 Gordon AR, Austin SB, Schultz J, Guss CE, Calzo JP, Wang ML. Gender expression, peer victimization, and disordered weight-control behaviors among U.S. high school students. J Adolesc Health 2021; 68(6):1148-1154. and those in development (9.6% to 30.7%)¹⁶16 Hidalgo-Rasmussen CA, Martín AH, Rasmussen-Cruz B, Montaño-Espinoza R. Calidad de vida, según percepción y comportamientos de control del peso por género, en estudiantes universitarios adolescentes en México. Cad Saude Publica 2011; 27(1):67-77.^,1717 Tuffa TA, Gebreyesus SH, Endris BS, Getnet Y, Abebe DS. Unhealthy weight control behaviors among Ethiopian female adolescents. Int J Eat Disord 2020; 53(4):525-532.. In Brazil, a study conducted with the three surveys (2009, 2012, and 2015) of the National School-Based Health Survey (PeNSE), recorded a temporal trend of increased prevalence of EWLB among adolescents living in Brazilian capitals, with estimates of 6,4% in 2009, 9.0% in 2012 and 10.1% in 2015⁴4 Ferreira CS, Andrade FB. Tendência de atitudes extremas em relação ao peso em adolescentes e sua relação com suporte familiar e imagem corporal. Cien Saude Colet 2020; 25(5):1599-1606..

The increased occurrence of EWLB in adolescence is explained by various individual (biological and psychological) and socio-cultural factors identified as potential risks for the adoption of these behaviors. Evidence shows that body image dissatisfaction, followed by overweight/obesity, are determinants for adoption of EWLB⁶6 Santana ML, Assis AM, Silva RC, Raich RM, Machado ME, Pinto EJ, Moraes LT, Ribeiro HC. Risk factors for adopting extreme weight-control behaviors among public school adolescents in Salvador, Brazil: a case-control study. J Am Coll Nutr 2016; 35(2):113-117.^,1818 Castro IRR, Levy RB, Cardoso LO, Passos MD, Sardinha LMV, Tavares LF, Dutra SP, Martins A. Imagem corporal, estado nutricional e comportamento com relação ao peso entre adolescentes brasileiros. Cien Saude Colet 2010; 15(Supl. 2):3099-3108. and that the higher frequency of family meals is associated with lower chances of adopting these behaviors¹⁹19 Loth K, Wall M, Choi CW, Bucchianeri M, Quick V, Larson N, Neumark-Sztainer D. Family meals and disordered eating in adolescents: are the benefits the same for everyone? Int J Eat Disord 2015; 48(1):100-110..

In this direction, in northeastern Brazil cultural values guide the way the northeastern relates to food and weight, also, is the region that has the largest coastline and high climatic temperatures most of the year, which is associated with greater body exposure with the adoption of light clothing for boys and girls²⁰20 Iriart JAB, Chaves JC, Orleans RG. Culto ao corpo e uso de anabolizantes entre praticantes de musculação. Cad Saude Publica 2009; 25(4):773-782.^,2121 Alves TCHS, Santana MLP, Silva RCR, Pinto EJ, Assis AMO. Fatores associados a sintomas de transtornos alimentares entre escolares da rede pública da cidade do Salvador, Bahia. J Bras Psiquiatr 2012; 61(2):55-63.. Thus, it is assumed that northeastern adolescents are more vulnerable to social pressures to adapt their body image to a socially established standard, which can differentiate the way EWLB develops. Therefore, the dissolution of cultural boundaries and the resulting homogenization of values relativized this premise, emerging as one more element to justify the conduction of this study on this theme in this region.

Then, considering the complex and multifactorial nature of EWLB and the need to deepen knowledge on this topic, this study was guided by the hypothesis that socioeconomic and demographic characteristics, family, individual, and psychological behaviours are related to the development of EWLB in adolescents. Thus, the present study was developed to assess, based on PeNSE²²22 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2015. Rio de Janeiro: IBGE; 2016. of 2015, the prevalence and factors associated with unhealthy behaviors in adolescents of northeastern Brazil.

Methods

This is a cross-sectional study, using data from Sample 2 of the PeNSE 2015 edition, collected from a complex sampling design²²22 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2015. Rio de Janeiro: IBGE; 2016.. This study followed the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology - STROBE.

The national sample consisted of students who attended from 6^th to 9^th grade of elementary school and from 1^st to 3^rd grade of high school in public and private schools located in urban and rural areas of the five geographic regions of Brazil. This study adopted the section of the Northeast region with 3,230 adolescents. Data from 791 questionnaires were excluded due to the absence of the variable maternal education, so 2,439 adolescents were included in the analysis. The design of the study sample selection is shown in Figure 1.

Data collection was performed with electronic devices (smartphones) in a self-administered electronic questionnaire. The researchers from the Brazilian Institute of Geography and Statistics (IBGE) distributed the devices to the students on the day of the interviews and introduced them to how to use them. In addition to the questionnaire, anthropometric measurements of weight and height were performed to assess the body mass index (BMI) of students. PeNSE’s data is in the public domain and details about the sampling strategy and other research information can be found in the report of its third edition held in 2015²²22 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2015. Rio de Janeiro: IBGE; 2016.. This nationwide research was approved by the Research Ethics Committee of the Ministry of Health of Brazil, approval nº 192/2012, referring to registration n^o 16,805, from CONEP/MS, from 27/3/2012.

The outcome variable, EWLB, was constructed based on two simple questions: “Did you vomit or take laxatives to lose weight or avoid gaining weight? “ (yes/no) and “have you taken any medicine, formula, or other weight loss product without medical follow-up?” (yes/no)²²22 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2015. Rio de Janeiro: IBGE; 2016.. A negative answer classified the participant with absence (0 = reference) of EWLB, and if the answer was affirmative for at least one of the questions was considered presence (1) of these behaviors in adolescents.

The exposure variables represent categories related to socioeconomic and demographic factors, family, individual and psychological behavior, and are described in Chart 1.

Initially, the descriptive analysis was performed to characterize the study population using frequencies. Then, the Pearson’s chi-square test was performed to compare the prevalence of EWLB according to the exposure variables. The statistical analysis was performed following a predefined conceptual model like that suggested by Victora et al.²⁵25 Victora CG, Huttly SR, Fuchs SC, Olinto MT. The role of conceptual frameworks in epidemiological analysis: A hierarchical approach. Int J Epidemiol 1997; 26(1):224-227. to map the relationships proposed between the EWLB and the variables of interest. This structure is organized in blocks and distributed in three levels (Figure 2).

Poisson regression models were adjusted to identify potential factors associated with EWLB. The initial model included all Level 1 variables (Figure 2). Those statistically significant (p < 0.05) in this first model contributed to the adjustment of subsequent levels of analysis. The second model included all Level 2 variables and those that were significant (p < 0.05) in the initial model. Then, a new model was adjusted with the variables of Level 2 that were significant (p < 0.05), in addition to the variables selected in the initial model and all variables of Level 3. After checking the statistical significance (p < 0.05) for the variables of Level 3, the final model was adjusted. Also, the variables of economic indicator and race/skin color were maintained in all steps of the analysis, although they were not statistically significant (p < 0.05). Statistical analyses were performed using the software R (R Version 4.1.2 - “Bird Hippie”)²⁶26 R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria; 2021..

Results

Of the 2,439 adolescents, 51.6% were female, 54.4% were aged 15 to 19 years, and 70.0% belonged to the public school system (Table 1). The prevalence of EWLB was 12.1%, with 8.5% reporting self-induced vomiting or use of laxatives and 7.1% using medicine or other products to lose or maintain weight. Other characteristics of the sample and prevalence of EWLB are described in Table 1.

The results of the simple Poisson model indicated that among the factors of the distal level, being female (PR: 0.60; CI: 0.46-0.79) and aged 15 to 19 years (PR: 0.56; CI: 0.41-0.77) were negatively associated with EWLB. There was also a negative association between mothers having completed high school or college and adolescents studying in private schools (Table 2).

Among the factors of the intermediate level, the prevalence of EWLB is about 2.09 (CI: 1.56-2.82) times higher in adolescents who suffered bullying related to body appearance and for other reasons compared to their peers who did not suffer psychological violence. More expressive and positively significant estimates were also observed when assessing the sexual abuse suffered (PR: 3.08; CI: 2.22-4.26) by the adolescent and the outcome of interest. There was no significant association between the other variables at this level and the occurrence of EWLB (Table 2).

Regarding the proximal level, the results showed that feeling lonely (PR: 1.58; CI: 1.22-2.03), having insomnia (PR: 1.91; CI: 1.48-2.46), being obese (PR: 1.81; CI: 1.32-2.46), self-perception of excess weight (PR: 1.53) and body image dissatisfaction (PR: 1.44; CI: 1.12-1.84) were significantly and positively associated with EWLB. The other variables in this level were not associated with the outcome of interest (Table 2).

In the final model, after adjustment, it was observed that female (PR = 0.65; CI = 0.52-0.81), aged 15 to 19 years (PR = 0.56; CI = 0.45-0.70), private school (PR = 0.62; CI = 0.46-0.84), while representative of the distal level decreased the prevalence of adoption of EWLB. Regarding the intermediate level, it was found that experiencing violence as being a victim of bullying related to body appearance and for other reasons (PR = 1.62; CI = 1.19-2.20) and being forced to have sexual intercourse (PR = 2.65; CI = 1.90-3.69) showed positive and significant associations with the occurrence of EWLB. Regarding the factors of the proximal level, having insomnia (PR = 1.84; CI = 1.43-2.37) and self-perception of excess weight (PR = 1.90; CI = 1.50-2.42) increased almost twice the prevalence of the outcome of interest (Table 2).

Discussion

This study evaluated the prevalence and factors associated with the adoption of EWLB among adolescents from northeastern Brazil. The estimated prevalence of EWLB among adolescents (12.14%) in this study was higher than that observed throughout Brazil in the three PeNSE surveys, 6.4% in 2009, 9.0% in 2012, and 10.1% in 2015⁴4 Ferreira CS, Andrade FB. Tendência de atitudes extremas em relação ao peso em adolescentes e sua relação com suporte familiar e imagem corporal. Cien Saude Colet 2020; 25(5):1599-1606. or among Spanish (3.26%) and North American adolescents (5.03%)²⁷27 López-Guimerà G, Neumark-Sztainer D, Hannan P, Fauquet J, Loth K, Sánchez-Carracedo D. Unhealthy weight-control behaviours, dieting and weight status: a cross-cultural comparison between North American and Spanish adolescents. Eur Eat Disord Rev 2013; 21(4):276-283., but it was lower than the estimates for adolescents from southeastern Brazil (31.9%)²⁸28 Silva SU, Barufaldi LA, Andrade SSCA, Santos MAS, Claro RM. Estado nutricional, imagem corporal e associação com comportamentos extremos para controle de peso em adolescentes brasileiros, Pesquisa Nacional de Saúde do Escolar de 2015. Rev Bras Epidemiol 2018; 21(Supl. 1):e180011.. The variability of the prevalence found may have been influenced by the sociocultural aspects inherent to each location and methodological differences adopted by the studies to assess the outcome. These results of the estimated prevalence of EWLB related to body and weight should raise concerns, especially in adolescence, considered an important starting point for the development of eating disorders, which can result in numerous consequences for physical and mental health.

Among the variables explored in the final model, the results indicated that studying in private school, being a victim of bullying related to body appearance and for other reasons, being forced to have sexual intercourse, having insomnia, and self-perception of excess weight were associated with EWLB among the adolescents assessed.

Considering the final model adjusted by the economic indicator, self-reported race/skin color, and all the variables of the model, this study showed that the school administration (private) reduced the prevalence of EWLB. Similar results²⁸28 Silva SU, Barufaldi LA, Andrade SSCA, Santos MAS, Claro RM. Estado nutricional, imagem corporal e associação com comportamentos extremos para controle de peso em adolescentes brasileiros, Pesquisa Nacional de Saúde do Escolar de 2015. Rev Bras Epidemiol 2018; 21(Supl. 1):e180011.^,2929 Austin SB, Richmond TK, Spadano-Gasbarro J, Greaney ML, Blood EA, Walls C, Wang ML, Mezgebu S, Osganian SK, Peterson KE. The contribution of school environmental factors to individual and school variation in disordered weight control behaviors in a statewide sample of middle schools. Eat Disord 2013; 21(2):91-108. was presented, in which the presence of these behaviors was higher among adolescents enrolled in public schools. These results may be related to the socioeconomic conditions of these students, which is a hypothesis to be tested in future studies, since studying in public school is a proxy for worse economic conditions and previously it was supposed that these behaviors were more frequent in higher income populations. However, it has often been observed that people from lower social classes are more vulnerable to pressures to adapt to a socially established body standard³⁰30 Stephen EM, Rose JS, Kenney L, Rosselli-Navarra F, Weissman RS. Prevalence and correlates of unhealthy weight control behaviors: findings from the national longitudinal study of adolescent health. J Eat Disord 2014; 2:16..

The results also show that adolescents who experienced appearance-related bullying were more likely to adopt EWLB and this is in line with previous findings among youngsters³¹31 Lampard AM, MacLehose RF, Eisenberg ME, Neumark-Sztainer D, Davison KK. Weight-related teasing in the school environment: Associations with psychosocial health and weight control practices among adolescent boys and girls. J Youth Adolesc 2014; 43(10):1770-1780.^,3232 Menzel JE, Schaefer LM, Burke NL, Mayhew LL, Brannick MT, Thompson JK. Appearance-related teasing, body dissatisfaction, and disordered eating: a meta-analysis. Body Image 2010; 7(4):261-270.. Mostly, adolescents who have been victims of appearance-related bullying, feel more uncomfortable with teasing, which contributes to body dissatisfaction and EWLB. This result is particularly relevant, and this situation should be monitored, as other studies have also shown an association between bullying and problems related to emotional distress, such as loneliness, anxiety, insomnia, sadness, depression, post-traumatic stress disorder, and suicidal thoughts³³33 Henry KL, Lovegrove PJ, Steger MF, Chen PY, Cigularov KP, Tomazic RG. The potential role of meaning in life in the relationship between bullying victimization and suicidal ideation. J Youth Adolesc 2013; 43(2):221-232., showing the extent of this problem and its serious immediate and long-term health consequences.

Furthermore, the results reveal significant associations between experiences of sexual abuse and the outcome of interest. There are numerous psychological consequences of sexual abuse suffered by adolescents, including the development of eating disorders. This mechanism is related to body dissatisfaction, which acts as a mediator throughout the process since the victims of this violence have a sense of discomfort and dissatisfaction with their self-image seeking body changes through inadequate eating behavior³⁴34 Ackard DM, Neumark-Sztainer D. Multiple sexual victimizations among adolescent boys and girls: prevalence and associations with eating behaviors and psychological health. J Child Sex Abus 2003; 12(1):17-37.

35 Paraventi F, Claudino AM, Morgan CM, Mari JJ. Estudo de caso controle para avaliar o impacto do abuso sexual infantil nos transtornos alimentares. Arch Clin 2011; 38(6):222-226.^-3636 Rocha DB, Andrade AC, Silva CAB. Vidas atravessadas pelo abuso sexual e pelo transtorno alimentar. Inv Quali Saude 2018; 2:727-736.. Early interventions are essential so that a specific diagnostic proposal is built to better serve populations at risk and minimize the damaging effects of this violence.

Regarding the psychosocial indicators, having insomnia increased the prevalence of the outcome of interest, aligning with the result presented in other studies, in which adolescents with sleep duration of at least 8 hours per day act as a protective factor against EWLB for both sexes³⁷37 Weng CB, Sheu JJ, Chen HS. Factors associated with unhealthy weight control behaviors among a representative sample of U.S. high school students. J Sch Nurs 2022; 38(6):533-546 .. It is believed that this association can be explained by dissatisfaction with body image, because poor sleep quality, in addition to causing hormonal changes, increases physical inactivity and the time available for food intake mainly of high energy density foods and low nutritional value, and even prolonged exposure to television, which may lead adolescents to present distorted body image, thus favoring the adoption of EWLB³⁸38 Lima FEB, Coco MA, Santos DR, Lima SBS, Lima WF. Relação entre imagem corporal, consumo alimentar e sono em adolescentes. Rev Assoc Med RS; 65(3):01022105..

Consistent with previous studies⁵5 Vale D, Dantas RF, Amorim GKD, Lyra CO, Oliveira AGRC. Determinantes sociais de comportamentos alimentares desordenados entre adolescentes brasileiros. Rev Debat Psiquiat 2021; 11:1-22.^,66 Santana ML, Assis AM, Silva RC, Raich RM, Machado ME, Pinto EJ, Moraes LT, Ribeiro HC. Risk factors for adopting extreme weight-control behaviors among public school adolescents in Salvador, Brazil: a case-control study. J Am Coll Nutr 2016; 35(2):113-117.^,77 Leme AC, Philippi ST, Thompson D, Nicklas T, Baranowski T. ''Healthy habits, healthy girls - Brazil'': an obesity prevention program with added focus on eating disorders. Eat Weight Disord 2019; 24:107-119.^,1818 Castro IRR, Levy RB, Cardoso LO, Passos MD, Sardinha LMV, Tavares LF, Dutra SP, Martins A. Imagem corporal, estado nutricional e comportamento com relação ao peso entre adolescentes brasileiros. Cien Saude Colet 2010; 15(Supl. 2):3099-3108.^,3939 Leal GVDS, Philippi ST, Alvarenga MDS. Unhealthy weight control behaviors, disordered eating, and body image dissatisfaction in adolescents from São Paulo, Brazil. Braz J Psychiatry 2020; 42(3):264-270. self-perception of excess weight was significantly associated with adolescent involvement with EWLB. In contemporary society, adolescents with a greater possibility of involvement in strategies for weight loss probably have a high level of body image dissatisfaction, such as stress with appearance. The hypothesis that body image perception may have a greater impact on EWLB that favors weight loss is reinforced by considering, for example, that normal-weight adolescents who overestimate their nutritional status are more likely to adhere to fasting practices, self-induced vomiting, or use of laxatives and over-the-counter drugs when compared with those with normal weight and self-assessment in accordance with their real weight²⁸28 Silva SU, Barufaldi LA, Andrade SSCA, Santos MAS, Claro RM. Estado nutricional, imagem corporal e associação com comportamentos extremos para controle de peso em adolescentes brasileiros, Pesquisa Nacional de Saúde do Escolar de 2015. Rev Bras Epidemiol 2018; 21(Supl. 1):e180011..

This study, for analysis of PeNSE data, is a pioneer in Brazil in evaluating the factors associated with EWLB with a hierarchical approach and a large region of the country. The results suggest potential implications for public health, yet this study has some limitations that should be considered for the interpretation of the results. First, as PeNSE is cross-sectional research, there is the possibility of causality bias because the relationship between outcome and exposure variables was estimated in a single moment. The temporal sequence of events was not considered, and the cause and effect could not be identified. Second, the sample studied was from a single Brazilian region and, therefore, is not representative of all adolescents in the country. However, the sample size was adequate (with adequate power and effect size) for the analyses and attested conclusions. Third, PeNSE²²22 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar 2015. Rio de Janeiro: IBGE; 2016. presents: the use of self-report for the research of extreme weight loss behaviors with the possibility of underreporting, because the adolescent can be inhibited, not reporting accurately, and may be subject to classification errors.

Despite the limitations of this study, it can be concluded that among the adolescents assessed there is a worrying prevalence of EWLB, and that studying in private school, being a victim of bullying related to body appearance and for other reasons, being forced to have sexual intercourse, having insomnia and self-perception of weight excess are important factors associated with these disorderly behaviors. The impact of these results on public and mental health involves the fact that early identification of EWLB can help prevent more serious health problems that burden the public health system.

In this perspective, these results, as well as all others from PeNSE, should be widely disseminated to subsidize actions to be implemented, expanded, and/ or reformulated. In addition, these findings can help to inform policies and programs for the prevention of EWLB and protection of young people, to monitor the magnitude and temporal trends of these factors, as well as to evaluate the actions addressed to this population group. The EWLB affects the physical and mental health of adolescents and therefore requires an integrated approach to coping with this problem that involves educators, health professionals, parents, and the community in general. These initiatives should focus on health promotion and protection, comprehensiveness, and intersectorality.

Acknowledgment

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Funding Code 001. The authors thank the Fundação de Amparo à Pesquisa do Estado da Bahia (FAPESB) for awarding the scholarship to the graduate student (Ph.D.) and for supporting this research.

References

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