Weight misperception and non-fatal suicidal behaviors among U.S. adolescents: A V-shaped association and gender...

Existing evidence has identified that both weight overestimation and underestimation may elevate the risk of mental health issues in adolescents, such as depression and other externalizing and internalizing symptoms. However, this V-shaped association remains unclear with non-fatal suicidal behaviors (NFSB, including suicidal ideation, plan, and attempt), a serious mental health concern. Measurement and gender might account for that uncertainty.

Based on a representative pooled U.S. cross-sectional Youth Risk Behavior Survey across five biennial cycles (2013-2021, n = 47,784; 50.6 % female), we first reconstructed a continuous measure of weight misperception using normalization techniques to mitigate the limitation of traditional categorical measures. We then examined its non-linear association with NFSB using restricted cubic spline technique in R. For comparability and interpretability, the continuous variable was further converted into a three-category measure to evaluate its V-shaped relationship with NFSB overall and by gender through logistic regression in Mplus. To obtain a more generalizable conclusion, year-specific estimates were synthesized using meta-analysis.

Compared to accurate perception group, both the overestimation and underestimation groups exhibited a higher risk of NFSB. This V-shaped association showed a significant gender difference, remaining evident among females but not among males, in whom underestimation was not significantly associated with NFSB. Meta-analysis found both weight overestimation (ORs: 1.82, 1.69, 1.69) and underestimation (ORs: 1.39, 1.36, 1.42) significantly increased odds of suicidal ideation, plan, and attempt, with consistently stronger associations for overestimation.

Weight misperception exhibits an independent V-shaped association with NFSB, with gender-related heterogeneity implying the involvement of distinct underlying mechanisms.