Weight-loss practices and dietary quality in Chinese adolescents

INTRODUCTION: This cross-sectional study aimed to investigate the associations between various weight-loss practices and unhealthy dietary patterns among Chinese adolescents. METHODS: We analyzed 17,483 students aged 6-19 years from The Zhejiang Childhood Behavior and Health Cohort, a school-based, multistage stratified cluster sample. Six weight-loss behaviors (laxatives, vomiting, non-prescribed diet pills, dieting/low-calorie foods, ≥ 24 h fasting, increased exercise) were assessed with yes/no items. Dietary quality was quantified with the 8-item Unhealthy Dietary Score (UDS-8; range 0-80, and categorized into low, moderate and high unhealthy dietary groups. Multivariable logistic regression estimated adjusted odds ratios (OR, 95% CI) for the association between each weight-loss method and dietary category. RESULTS: In the fully adjusted model, fasting ≥ 24 h conferred the highest risk of high unhealthy diet scores overall (OR = 4.65, 95% CI: 2.90-7.44), followed by vomiting (OR = 4.75, 95% CI: 2.25-10.00), diet pills (OR = 4.03, 95% CI: 1.90-8.56), and laxatives (OR = 2.65, 95% CI: 1.60-4.39), while increased exercise remained protective (OR = 0.83, 95% CI: 0.74-0.92). BMI-stratified analyses revealed that underweight adolescents showed the strongest associations for fasting (OR = 8.21) and vomiting (OR = 5.43); among those with overweight or obesity, fasting remained significant (OR = 3.32) and exercise showed the strongest protective effect (OR = 0.54); among normal-weight adolescents, dieting (OR = 1.59) and fasting (OR = 2.47) were significantly associated with high unhealthy diet, whereas exercise showed no significant association (OR = 1.03, 95% CI: 0.78-1.35). Notably, the associations between extreme weight-loss behaviors (e.g., vomiting, fasting ≥ 24 h) and unhealthy diet scores were more pronounced among underweight and obese adolescents, revealing important BMI-stratified heterogeneity. CONCLUSION: Extreme weight-control behaviors are strongly coupled with poor-quality diets among adolescents, with BMI-stratified heterogeneity, whereas increased exercise predicts healthier eating. School-based programs should prioritize the identification of extreme weight-loss behaviors and promote physical activity and balanced diets to prevent disordered eating.