The evidence comes from an unusually large and geographically diverse sample. Using a multistage stratified cluster sampling design, the team selected five provincial-level administrative regions to represent China’s major geographic areas: Guangdong in the south, Heilongjiang in the northeast with the survey conducted in Harbin, Xinjiang in the northwest, Anhui in the east, and Henan in central China. Within each region, six rural areas were chosen as test sites, and two complete secondary schools were selected within each area, producing 60 rural schools in total. The survey was carried out during the 2024–2025 academic year among junior and senior high school students aged 12 to 18 whose parents and the students themselves held rural household registration and voluntarily agreed to participate. Of 53,041 students assessed, 306 were excluded for damaged questionnaires, missing key demographic information, or refusal, leaving 52,735 valid responses, a questionnaire validity rate of 99.42 percent. The final sample comprised 26,043 boys and 26,692 girls with an average age of 15.09 years.

The headline prevalence figure is substantial. Overall, 21.8 percent of the rural adolescents screened positive for psychological symptoms, a rate the authors note exceeds the 20.3 percent reported in one nationwide survey of Chinese adolescents and the 21.2 percent found in another. Notably, the prevalence was significantly higher among boys than girls, at 22.5 percent versus 21.2 percent, a difference the researchers suggest may reflect traditional Chinese cultural values in which males bear greater social and familial responsibilities and families place higher educational expectations on boys. They also point out that males often prefer to process psychological issues independently, whereas females tend to seek relief through confiding in peers. Within the symptom profile, emotional problems affected 26.9 percent of the sample, behavioral problems 25.8 percent, and social adjustment difficulties 17.8 percent, with sex differences reaching statistical significance for behavioral problems and social adjustment difficulties but not for emotional problems.

The body composition measure at the center of the analysis is a body shape index, or ABSI, proposed by researcher Nir Krakauer in 2012 to address a key limitation of traditional body mass index, which cannot distinguish how body fat is distributed. ABSI is derived from three dimensions combined in a single formula: waist circumference in meters divided by body mass index raised to the power of two-thirds, multiplied by height raised to the power of one-half. Waist circumference captures abdominal fat accumulation, body mass index assesses overall obesity through the relationship between weight and height, and height standardizes body proportions. According to the authors, ABSI better reflects the body’s visceral fat content than either body mass index or waist circumference alone, shows superior predictive value for chronic disease onset, and predicts all-cause mortality risk independently of body mass index with particular sensitivity for so-called normal-weight obesity, in which individuals have normal body mass index but excessive waist circumference. In this sample, the mean ABSI score was 0.06, with a standard deviation of 0.01.

Exposures and outcomes were assessed with validated instruments. Sugar-sweetened beverage consumption was evaluated using a self-administered food frequency questionnaire covering the frequency of drinking both sugar-sweetened and sugar-free soft drinks, with response options ranging from never or less than once a month to six or more times per day. For analysis, consumption was grouped into three categories: less than two times per week, three to five times per week, and more than five times per week. Psychological symptoms were screened with the Brief Adolescent Mental Health Screening Questionnaire, a 15-item instrument covering emotional problems, behavioral problems, and social adjustment difficulties over the preceding six months, with a total score of seven or above signaling psychological symptoms. Physical measurements of height, weight, and waist circumference followed National Student Physical Fitness Survey protocols. The team adjusted for standing long jump performance, parental education, commuting method to school, snack consumption, and sleep duration, constructing three sequential logistic regression models of increasing adjustment.

The independent associations were consistent across the fully adjusted model. Adolescents in the highest body shape index quartile, above the 75th percentile, had 1.23 times the odds of psychological symptoms compared with those below the 25th percentile, with a 95 percent confidence interval of 1.16 to 1.31. Adolescents who consumed sugary drinks more than five times per week had 1.21 times the odds compared with those drinking less than twice a week, with a confidence interval of 1.13 to 1.30. The pattern held in sex-stratified analyses: among boys, the highest quartile carried an odds ratio of 1.28 and heavy sugary drink consumption an odds ratio of 1.14, while among girls the corresponding figures were 1.20 and 1.23. Univariate comparisons showed that the prevalence of psychological symptoms rose continuously with increasing levels of both sugary drink consumption and body shape index quartiles, from 19.9 percent in the lowest quartile to 23.9 percent in the highest, and from 20.5 percent in the lightest drink category to 25.6 percent in the heaviest.

The combined analysis produced the study’s most striking result. Using binary logistic regression embedded within a generalized linear model, with all covariates adjusted, adolescents who consumed sugary drinks more than five times per week and fell within the 51st to 75th percentile of the body shape index showed the highest odds of psychological symptoms of any joint category, at 2.40 times the reference group of light drinkers in the lowest quartile. The authors emphasize an important technical caveat: this combined-category analysis describes the joint distribution of the two exposures across strata and does not constitute a formal statistical test of interaction, since no multiplicative interaction term was added to the model. It should therefore not be interpreted as evidence of synergy or antagonism between sugary drink intake and body shape. Even so, the pattern remained consistent in sex-stratified analyses, with odds ratios of 2.42 among boys and 2.33 among girls in the same combined category.

The findings arrive against a backdrop of converging trends. A meta-analysis encompassing more than 1.38 million participants estimated the pooled prevalence of adolescent psychological symptoms at 30 percent, with a clear upward trend, and national surveys in China report a prevalence of 31 percent among adolescents. A longitudinal study found that from 2018 to 2022, the prevalence of psychological symptoms among rural Chinese adolescents, at 35.10 percent, exceeded that of urban counterparts at 30.16 percent, with a faster rate of increase. On the beverage side, global average weekly consumption of sugar-sweetened beverages stood at 2.6 cups in 2020, and consumption is projected to rise approximately 9.54 percent by 2050, with the center of gravity shifting toward developing countries. In China, deaths attributable to excessive sugary drink intake reached 46,000 in 2019, a 95 percent increase compared with 1990. Among United States adults, drinking sugary beverages at least once per day was associated with a 26 percent higher prevalence of reporting poor mental health for 14 or more days during the preceding month.

The mechanisms the authors propose remain speculative, and they are explicit that the study included no biomarkers of inflammation, insulin resistance, or gut microbiota to test them. From a body composition perspective, frequent sugary drink consumption has been associated with obesity and adverse indicators such as hyperlipidemia, high cholesterol, and mild inflammation, which observational studies have linked to increased odds of psychological symptoms. Elevated abdominal fat accumulation has been hypothesized to be associated with low-grade systemic inflammation, which in turn is closely associated with psychological symptoms. From a dietary behavior perspective, sugary drink consumption rarely occurs in isolation but coexists with fast food, fried foods, and ultra-processed food intake, suggesting it may indicate poorer overall dietary quality; nutrient imbalances have been hypothesized to alter the gut microbiota environment and influence brain function through the gut–brain axis. High sugar intake may also cause significant fluctuations in blood glucose levels and disrupt neurotransmitters, inducing emotional fluctuations. Finally, elevated body shape index levels may lower satisfaction with physical appearance, and a meta-analysis of 26 studies found obese adolescents face a 46 percent higher risk of bullying compared with normal-weight children, a risk more pronounced among boys.

The authors acknowledge several limitations that temper the conclusions. The cross-sectional design precludes any causal inference, and prospective cohort studies are needed to establish temporality. Reliance on self-reported questionnaires may introduce measurement bias and recall error. The covariate set was restricted: physical activity, sedentary or screen time, smoking, alcohol use, family income, and caffeine intake were not measured and could not be adjusted for. Because students were recruited through cluster sampling at the school level and share dietary habits and family backgrounds, and the regression models did not account for this clustering, the estimated confidence intervals may be somewhat narrower than those from fully independent samples, and future analyses using multilevel models or cluster-robust variance estimation are warranted. Within those boundaries, the team concludes that both independent and combined associations were observed between sugary drink consumption, the body shape index, and psychological symptoms among rural Chinese adolescents, and that future interventions targeting psychological symptoms in this population may consider sugary drink intake and body shape as modifiable targets, while interpreting the associations as anything but causal.

Subject of Research: Associations between sugar-sweetened beverage consumption, a body shape index, and psychological symptoms among rural Chinese adolescents

Article Title: A cross-sectional study on the associations between sugar- sweetened beverage consumption, a body shape index, and psychological symptoms among rural Chinese youth

Article References: Zeng, C. G., Chai, C., Xu, J., Sha, M., & Xin, J. (2026). A cross-sectional study on the associations between sugar- sweetened beverage consumption, a body shape index, and psychological symptoms among rural Chinese youth. Frontiers in Nutrition, 13, Article 1913391. https://doi.org/10.3389/fnut.2026.1913391

Image Credits: AI Generated

DOI: 10.3389/fnut.2026.1913391

Keywords: adolescent mental health, sugar-sweetened beverages, a body shape index, rural China, cross-sectional study, psychological symptoms, nutrition, public health, cross-sectional, associations, between, sugar-