Commentary

Adolescent Tanning, Disordered Eating, and Risk Taking David C. Schwebel, PhD ABSTRACT: Indoor tanning and eating disorder behaviors are both significant adolescent public health risks. Recent results by Amrock and Weitzman provocatively suggest a link between the two, perhaps because of a shared cause of dysfunctional cognition about body image. This commentary discusses a possible model to explain the association between indoor tanning and eating disorder behaviors among teenagers. It also presents various strategies to prevent the negative outcomes, with a focus on preventing adolescent tanning behavior. Prevention strategies worth consideration include counseling by pediatricians or other health professionals, improved parental supervision and monitoring, and policy change to prohibit adolescent use of tanning facilities. (J Dev Behav Pediatr 35:225–227, 2014) Index terms: adolescents, tanning, eating disorders, risk taking, prevention, policy.

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read Amrock and Weitzman’s excellent article on adolescent indoor tanning and eating disorder behaviors1 while traveling on an airplane, seated by happenstance next to 2 preteen girls aged 9 and 12. I did not know the girls personally, and they did not know each other, but they struck me as healthy and well adjusted. When I asked them about tanning, they denied ever using indoor tanning facilities or even knowing any friends who used them. The older girl mentioned the risks of skin cancer from using tanning beds. Yet data from this article suggest that those 2 girls have a roughly 1-in-4 chance of engaging in indoor tanning in the coming several years. White girls, like 1 of my 2 seatmates appeared, have an 1in-3 chance, and their male counterparts are not immune either; boys have a roughly 1-in-15 chance of indoor tanning use.1 Epidemiological data on the other topic addressed by Amrock and Weitzman,1 eating disorder behaviors, are equally troubling. Preteens have a significant chance of developing eating disorders during their teenage years, with female American teenagers having higher risk than males and overall prevalence hovering between 1% and 5% (see 2,3 for reviews). How can we as medical professionals reduce health risks for my 2 preteen airplane companions and the millions of adolescents like them? Provocative data from Amrock and Weitzman, and rather convincing results given the scientific rigor the authors used, offer several hints.1 Below, I comment on the study itself and then discuss possible implications to reduce adolescent health risk. From the Department of Psychology, University of Alabama at Birmingham, Birmingham, AL. Received January 2014; accepted January 2014. Disclosure: The author declares no conflict of interest. Address for reprints: David C. Schwebel, PhD, Department of Psychology, University of Alabama at Birmingham, 1300 University Boulevard, CH 415, Birmingham, AL 35294; e-mail: [email protected]. Copyright Ó 2014 Lippincott Williams & Wilkins

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COMMENTS ON THE STUDY RESULTS Although one might not immediately expect links between indoor tanning and eating disorder behaviors among teens, Amrock and Weitzman’s data offer strong evidence to believe the relation is present, even after controlling for several confounders. The question that remains foremost for me is “why”? What drives the correlational link? Does dysfunctional eating behavior lead adolescents to desire indoor tanning? Does frequent indoor tanning lead to eating disorder behaviors? Or, the most likely possibility in my mind, does some third variable cause both risks? And further, if there is a third variable effect, what variable or variables might cause both indoor tanning and eating disorder behaviors among the same teens? Neurotic temperament, associated with anxiety, depression, substance use, and poor self-image4 seems a likely candidate. Adolescents with innate neurotic tendencies may develop clinical or subclinical anxiety, depression, and/or substance use. They may experience poor self-esteem, selfefficacy, and self-image. Such disordered behavior and dysfunctional cognitions may lead to poor body image. Poor body image is associated with both indoor tanning behavior and eating disorder behaviors. A quick Internet search offers hundreds of testimonials claiming that tanning makes one look thinner. Considered from an ecological or systems theory perspective, these youth may also be embedded in maladaptive environments. They may experience family environments that are chaotic, dysfunctional, and/or nonsupportive. Peer groups and peer relations may reinforce negative cognitions, especially concerning ideal and often-unachievable body image ideals. The peer or school culture may promote prominence of body image discussions and comparisons, ideals of slim and tan bodies, and obsession over attractiveness to potential dating partners. Extending to macrosystem influences, American adolescents are pervasively exposed to the images of popular culture on television, www.jdbp.org | 225

movies, and the Internet, which portray the oftenunachievable ideal body. Could this hypothesis be tested? Perhaps. Intensive longitudinal study of preadolescent and adolescent cohorts may offer relevant data. Cross-cultural comparisons could be particularly informative; for starters, it would be quite fascinating to determine whether links between indoor tanning and eating disorder behaviors emerge in other countries or cultures (including stratified analyses within racial/ethnic groups in Amrock and Weitzman’s sample). Intervention research could also speak to investigation of hypothesized causal pathways. If an intervention successfully stops the “chain” at one point (e.g., reducing dysfunctional cognition about body image), does this reduce multiple negative outcomes (e.g., both indoor tanning and disordered eating behaviors)?

IMPLICATIONS FOR PREVENTION OF HEALTH RISKS A discussion of prevention might incorporate both indoor tanning and eating disorder behaviors, but preventive strategies targeting both outcomes simultaneously is premature until causal mechanisms underlying the shared links are better understood. The literature on preventing and treating eating disorders is voluminous (see 5,6 for reviews), so I focus presently on discussion of preventing adolescent indoor tanning behavior, which may ultimately also reduce eating disorder behaviors. At least 2 possible prevention strategies for tanning behavior must be considered, behavioral and policy. From a behavioral perspective, as is the case of many child health behaviors, both cognition and actual behavior must be considered. Behavioral outcome is likely the result of maladaptive cognitions. Amrock and Weitzman1 explain that adolescents tan more often out of concern about negative body image than to achieve positive ideals about body image. Thus, the cognitive thought process may be to avoid negative appearance rather than to obtain an imagined positive image. From a prevention perspective, efforts to change behavior might be effective through cognitive restructuring. One option, offered by Amrock and Weitzman,1 is to initiate cognitive restructuring through counseling from professionals such as pediatricians. This strategy offers several merits and is used with some frequency to address other adolescent health behavior risk taking, such as risky sexual behavior7 and substance use.8 But pediatricians and their staff are increasingly handicapped by mandates for reimbursable time during well child checkups.9 Will counseling on indoor tanning and/or eating disorder behaviors rise to the top of a priority list for pediatricians? And even if it does, will a single, probably brief counseling interchange result in long-term behavior change among at-risk adolescents? I am pessimistic about the prospects. Other possibilities exist. Parents come to mind— should parents play a role? And will they? Unlike many 226 Commentary

adolescent health risk behaviors, tanning is not something adolescents can readily engage in furtively or secretly. Observant parents should recognize the consequences of adolescent tanning simply by examining their children’s skin tones and could potentially take action to prevent it. But despite well-publicized links between tanning behavior and skin cancer, adolescent tanning rates have not decreased over recent years,10 just as other adolescent risk behaviors (e.g., risky substance use, risky sexual behavior, and risky driving) have persisted for generations. Without explicit guidance, parents may have minimal effect on adolescent behavior and any explicit guidance would require substantial public health efforts. A third option, and one offering great appeal to me, is to initiate policy change to reduce adolescent tanning behavior. Policy change has proven quite successful to reduce other adolescent health risks (e.g., teen driving risk through graduated licensing laws11) and a 2010 federal tax on indoor tanning services suggests some policymakers are motivated to initiate change. Empirical evidence suggests, however, that legislation to prohibit adolescent tanning bed use may be even more effective than taxes, especially when enforced rigorously.10 On another recent airplane trip, I picked up a copy of USA Today and noted the headline, “States Face New Laws in New Year.”12 At the top of the article was report of a new state law in Illinois, banning youth under the age 18 from using tanning salons in the state. Illinois, reported in the article to be the sixth state to issue such a requirement, joined a small but growing group of jurisdictions that reduce health risks from tanning through policy. If enforced, Illinois’ adolescents may have greatly reduced skin cancer risk. Tanning beds could still be used in personal homes, and such use is apparently quite widespread with second-hand units selling for as little as $500 online, but medical professionals could have substantial impact on public health by means of implementation and enforcement of such laws nationwide and worldwide.

CONCLUSIONS Adolescents in today’s society face a myriad of broadranging health risks, indoor tanning and eating disorder behaviors among them. As health professionals, we are obliged to prioritize resources to intervene to reduce adolescent health risk behaviors. Such prioritization should consider both the ease with which the health risk behavior might be altered and the potential consequences of adolescents continuing to engage in the risky behaviors. Both indoor tanning and eating disordered behaviors can lead to serious and fatal consequences; for this reason alone, they must be included among our priorities. If they have shared cause, identifying interventions that reduce both risky behaviors holds appeal from the perspectives of pragmatism and economic efficiency. Solutions to reduce Journal of Developmental & Behavioral Pediatrics

problematic eating disorder behaviors remain challenging, yet achievable.5,6 Solutions to reduce indoor tanning behavior are less well understood, but both policy change and behavioral interventions hold promise. Together, we must continue to work toward improving adolescent health by encouraging and promoting healthy and enjoyable lifestyles among teens. ACKNOWLEDGMENTS Thanks to 2 anonymous airplane companions and the UAB Youth Safety Lab for valuable insights incorporated into this commentary.

REFERENCES 1. Amrock SM, Weitzman M. Adolescent indoor tanning use and eating disorders: results from the Youth Risk Behavior Survey. J Dev Behav Psychol. 2014;35:165–171. 2. Smink FRE, van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry Rep. 2012;14:406–414. 3. Swanson SA, Crow SJ, Le Grange D, et al. Prevalence and correlates of eating disorders in adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. 2011;68:714–723.

4. Ormel J, Rosmalen J, Farmer A. Neuroticism: a non-informative marker of vulnerability to psychopathology. Soc Psychiatry Psychiatr Epidemiol. 2004;39:906–912. 5. Stice E, Shaw H. Eating disorder prevention programs: a metaanalytic review. Psychol Bull. 2004;130:206–227. 6. Stice E, Shaw H, Marti CN. A meta-analytic review of eating disorder prevention programs: encouraging findings. Annu Rev Clin Psychol. 2007;3:207–231. 7. Henry-Reid LM, O’Connor KG, Klein JD, et al. Current pediatrician practices in identifying high-risk behaviors of adolescents. Pediatrics. 2010;125:e741–e747. 8. Hingson RW, Zha W, Iannotti RJ, et al. Physician advice to adolescents about drinking and other health behaviors. Pediatrics. 2013;131:249–257. 9. Cheng TL, DeWitt TG, Savageau JA, et al. Determinants of counseling in primary care pediatric practice: physician attitudes about time, money, and health issues. Arch Pediatr Adolesc Med. 1999;153:629–635. 10. Cokkinides V, Weinstock M, Lazovich DA, et al. Indoor tanning use among adolescents in the US, 1998 to 2004. Cancer. 2009;115:190– 198. 11. Vanlaar W, Mayhew D, Marcoux K, et al. An evaluation of graduated driver licensing programs in North America using a metaanalytic approach. Accid Anal Prev. 2009;41:1104–1111. 12. Toppo G. States Face New Laws in New Year. USA Today; 2013.

ERRATUM Anxiety Associated with Asthma Exacerbations and Overuse of Medication: The Role of Cultural Competency The article does not include the affiliation of one of the authors, John Takayama. His affiliation should have read as follows: Department of Pediatrics, University of California San Francisco. REFERENCE: 1. Horikawa YT, Udaka TY, Crow JK, Takayama JI, Stein MT. Anxiety Associated with Asthma Exacerbations and Overuse of Medication: The Role of Cultural Competency. J Dev Behav Pediatr 35:154–157, 2014.

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Adolescent tanning, disordered eating, and risk taking.

Indoor tanning and eating disorder behaviors are both significant adolescent public health risks. Recent results by Amrock and Weitzman provocatively ...
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