Eating disorders among college students in China: prevalence, correlates, and its relationship with suicide risk

Abstract

Background

Eating disorders (EDs) are prevalent among college students and may lead to severe consequences. This study aimed to examine the prevalence and correlates of EDs among Chinese college students and to investigate the relationship between EDs and suicide risk.

Methods

A cross-sectional study was conducted among 18,578 Chinese college students between October 17 and 29, 2023. Participants completed questionnaires assessing demographic characteristics, EDs, depression, anxiety, and suicide risk. Logistic regression analyses were performed to identify factors associated with EDs in the total sample, as well as factors associated with suicide risk among participants with EDs.

Results

The prevalence of EDs was 13.6% among Chinese college students. Multivariate logistic regression analysis revealed that body mass index, urban or town residence, left-behind experiences, maternal education at the senior high school level or above, depression, anxiety, suicidal ideation, and suicide attempts were independent correlates of EDs. Among participants with EDs, 19.5% reported suicidal ideation or suicide attempts. Variables such as age, left-behind experiences, chronic physical illness, family history of mental disorders, depression, and anxiety were independently associated with suicide risk.

Conclusion

EDs are prevalent among college populations and are associated with suicide risk. Therefore, it is imperative to specifically monitor suicide risk among individuals with EDs. Intervention strategies should focus on co-occurring depressive and anxiety symptoms to decrease suicidality in affected individuals.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s40337-026-01686-8.

Plain language summary

Eating disorders are prevalent among college students and are associated with severe adverse outcomes, including suicidality. This study examined the prevalence of eating disorders and their associated factors among Chinese college students. We surveyed 18,578 college students in China in October 2023. Results indicated that approximately 13.6% of the students had eating disorders. Students were more likely to have eating disorders if they had a high body mass index, urban residence, had left-behind experiences, maternal education of senior high school education or above, or had depression and anxiety. Furthermore, approximately 19.5% of students with eating disorders reported suicidal ideation or suicide attempts. These findings demonstrate that eating disorders and suicide risk often co-occur. Colleges should monitor suicide risk among students with eating disorders and provide interventions targeting depression and anxiety to ensure their safety.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s40337-026-01686-8.

Introduction

Eating disorders (EDs) refer to a persistent disturbance in eating or eating-related behaviors, such as anorexia nervosa, bulimia nervosa, and binge-eating disorder, resulting in altered food consumption or absorption [1]. EDs typically emerge during adolescence, with prevalence peaking in late adolescence and early adulthood [2, 3], making college years a critical high-risk period [4–6]. EDs not only impair college students’ social relationships and academic achievement but also pose grave threats to their physical and psychological well-being [7–9]. Early screening for EDs is especially critical for college students, as the global burden of EDs in this age group continues to rise [10].

Although several studies have indicated that EDs are more prevalent among college students, the reported prevalence rates have varied due to differences in samples, assessment instruments, and screening criteria. For instance, Qeadan et al. examined the 12-month prevalence of EDs among 414,299 U.S. college students using three self-developed questions and found that 7.15% reported such symptoms [11]. Using the Eating Attitude Test-26 (EAT-26), Chan et al. reported an ED prevalence of 13.9% among 1017 Malaysian college students [12], whereas Aljehani and Alabdrabalnabi observed a markedly higher prevalence of 27.1% among 771 participants at Saudi Electronic University [13], with the same instrument. To the best of our knowledge, there is a paucity of empirical data on the prevalence of EDs among college students in China. The few existing studies are limited by small sample sizes and are mostly published in Chinese, rendering them largely inaccessible to international readers. Bai and colleagues applied the EAT-26 to a sample of 271 Chinese college students and reported a prevalence rate of 17.0% [14]. Another Chinese study used the SCOFF questionnaire to survey 664 medical students and found that approximately 39.8% of participants screened positive for disordered eating [15]. Thus, there is an urgent need for large epidemiological studies to explore EDs among Chinese college students and to enrich the evidence base on EDs within the Chinese cultural context.

Previous work has identified influential factors associated with EDs. In terms of demographic factors, most studies have indicated that EDs are more prevalent among females than males [16, 17], although some have reported no significant sex difference [12]. Younger age [13], unmarried parents [18, 19], family economic insecurity [19], a family history of mental disorders [20], and higher body mass index (BMI) [13] are also associated with an increased risk of EDs. Substantial evidence indicates that EDs may also be associated with other psychopathologies, such as depression and anxiety [16, 21, 22].

Among these factors, suicidality has attracted special attention due to its devastating consequences. Suicide is the leading cause of death among young people aged 15–29 worldwide [23] and constitutes the most critical factor in non-natural deaths among college students in China [24]. Numerous studies have demonstrated that EDs are strongly associated with suicide risk, such as suicidal ideation [25] and suicide attempts [26]. However, after adjusting for confounding factors such as depression, this association became non-significant in several studies [27]. Since factors such as depression and anxiety have been associated with both EDs and suicide risk and these conditions often co-occur [21, 22, 28], the independent relationship between EDs and suicide risk needs to be further elucidated.

In addition, EDs are characterized by one of the highest mortality rates among psychiatric illnesses, particularly in young individuals [29–32], with a disproportionate number of these individuals dying by suicide [31, 33]. Given that individuals with EDs generally have a higher risk of suicidal behavior [34, 35], exploring the occurrence and determinants of suicide risk among college students with EDs is also of great importance, as it can provide data-driven insights for future clinical interventions.

Materials and methods

Study population

This study is part of a semester-based mental-health survey among Chinese college students; related findings have been reported elsewhere [36, 37]. In brief, we conducted a large-scale, web-based survey at four colleges/universities in Shanxi, Guangdong and Hunan provinces, China, using convenience sampling between 17 and 29 October 2023. A total of 19,236 students participated and submitted their questionnaires through the “Survey Star” platform. To enhance data quality, we applied the following exclusion criteria: (1) unusually short response times, (2) inconsistent identity details (e.g., incorrect student ID), (3) invalid responses (e.g., straight-lining), and (4) self-reported history of mental disorders. Ultimately, 658 cases were excluded, leaving 18,578 participants for the final analysis.

Prior to the survey, researchers distributed invitation letters to the students via their class WeChat groups. Students accessed the electronic questionnaire by scanning a QR code with their mobile phones; the online system performed a completeness check before submission was permitted. All participants—and their guardians for those under 18 years of age—provided electronic informed consent. They were informed that participation was voluntary and that they could discontinue or withdraw at any time without penalty should they experience discomfort. After the survey, we provided each university with a written report summarising the mental-health status of its students. Participants identified as being at high suicide risk were immediately referred to on-campus psychological-counselling services for appropriate support and intervention. All procedures were approved by the Health Research Ethics Committee of the School of Psychology, South China Normal University (approval No. SCNU-PSY-2023-345).

Measurements

EDs were measured with the Short Form of the Eating Disorder Examination Questionnaire (EDE-QS) [38]. The EDE-QS comprises 12 items, each rated on a 0–3 scale. Total scores range from 0 to 36, with higher scores indicating more severe disordered eating during the past week. The cut-off value of 15 represents clinical cases of EDs, with acceptable sensitivity (83%) and specificity (85%) [39]. To ensure that individuals who are currently experiencing or are likely to develop clinically significant EDs were not excluded, a slightly lower threshold was justified; accordingly, a cut-off score of 13 was adopted, following precedent in the literature [40, 41]. The Chinese version of EDE-QS has demonstrated adequate psychometric properties [42]. In the present study, the Cronbach’s α was 0.93.

Depressive symptoms were assessed using the Chinese version of the 2-item Patient Health Questionnaire (PHQ-2) [43]. Participants rated the frequency of the symptoms from 0-“not at all” to 3-“nearly every day”. Higher total scores indicate greater severity of depression in the past two weeks. A cutoff score of 3 has been identified as the best trade-off between sensitivity and specificity [44]. In the present study, Cronbach’s α was 0.82.

The 2-item Generalized Anxiety Disorder Questionnaire (GAD-2) was employed to assess participants’ symptoms of anxiety over the past two weeks [45]. Each item is rated on a 4-point scale ranging from 0-“not at all” to 3-“nearly every day”. A total score ≥ 3 was used to classify participants as having probable anxiety [46]. In the present study, Cronbach’s α was 0.87.

Suicide risk was assessed using the Three-Step Theory of Suicide (3ST) proposed by Klonsky et al. [47, 48]. Participants responded to three sequential screening questions: “Q1: Are you in pain and hopeless?”, “Q2: Does your pain exceed your connectedness?”, and “Q3: Do you have the capacity to commit suicide?” Each question was dichotomous (yes or no); only a “yes” response allowed progression to the next question, whereas a “no” response terminated the sequence. According to this theory [47, 48], suicidal ideation develops through the joint influence of psychological pain, hopelessness, and disrupted social connectedness, where the transition from ideation to attempt is governed by suicide capability. Suicide capability is currently the most empirically supported variable in distinguishing suicidal ideation from suicide attempts, and existing research has demonstrated a direct association between acquired suicide capability and suicide attempts [49]. Furthermore, prior studies have also indicated that suicide attempts primarily occur primarily among those who possess both strong suicidal ideation and the practical and mental capacity to act on those thoughts [50]. Thus, endorsement of Q1 was interpreted as suicidal ideation, endorsement of Q2 as strong suicidal ideation, and endorsement of Q3 as indicative of a suicide attempt. In the present study, we further categorized suicide risk into a three-level variable: [0 = no ideation; 1 = suicidal ideation; 2 = suicide attempt]. This screening method has been employed in previous studies [36, 51]. The screening flow is depicted in Fig. 1.

Fig. 1.

Three-step evaluation of suicidal behaviors in this sample

In addition, this study included a number of sample characteristic variables as covariates, including age, sex, ethnicity, parental marital status, residence location, single child status, parental education, family economic status, presence of chronic physical illness, family history of mental disorders, and BMI (kg/m²).

Statistical analysis

All statistical analyses were performed using SPSS version 24.0. Descriptive statistics were used to present sample characteristics and study variables. Categorical variables were expressed as frequencies (n) and percentages (%), whereas continuous variables were presented as means (M) and standard deviations (SD). Based on the EDE-QS cutoff score of 13 [40, 41], participants were screened for EDs. Univariate analysis (i.e., independent-samples t-tests for continuous variables and chi-square tests for categorical variables) was used to compare participants with and without EDs on sample characteristics, depression, anxiety, suicidal ideation, and suicide attempts. Multivariate logistic regression analysis was performed to identify factors independently associated with EDs. We also explored influential factors independently linked to suicide risk among participants with EDs using multivariate logistic regression analysis. All regression results are reported as odds ratios (ORs) and 95% confidence intervals (CIs), with statistical significance set at p < 0.05 (two-tailed).

Results

Descriptive statistics

A total of 18,578 college students were included in this study, with a mean age of 20.07 years (SD = 1.63). The proportion of females was higher than males (68.1% vs. 31.9%). The vast majority of participants (98.3%) were of Han ethnicity, the major ethnic group in China. Detailed sample characteristics are presented in Table 1.

Table 1.

Sample characteristics and clinical variables between participants with and without EDs [n(%), n = 18578]

Variables		Total (n = 18578)	EDs (n = 2535)	Non-EDs (n = 16043)	p-value
Age, years	M(SD)	20.07(1.63)	19.98(1.66)	20.08(1.62)	t = 2.75**
Body mass index	M(SD)	23.00(7.15)	25.08(7.51)	22.67(7.03)	t =−15.13 ***
	< 18.5 [underweight]	3384(18.2)	203(8.0)	3181(19.8)	χ2 = 522.85***
	18.5–23.9 [normal weight]	10,378(55.9)	1242(49.0)	9136(56.9)
	≥ 24 [overweight/obesity]	4816(25.9)	1090(43.0)	3726(23.3)
Sex	Male	5931(31.9)	885(34.9)	5046(31.5)	χ2 = 12.05***
	Female	12,647(68.1)	1650(65.1)	10,997(68.5)
Ethnicity	Han a	18,257(98.3)	2477(97.7)	15,780(98.4)	χ2 = 5.42*
	Others	321(1.7)	58(2.3)	263(1.6)
Parental marital status	Married	16,979(91.4)	2288(90.3)	14,691(91.6)	χ2 = 4.82*
	Not current married b	1599(8.6)	247(9.7)	1352(8.4)
Residence location	Rural	9332(50.2)	1133(44.7)	8199(51.1)	χ2 = 39.84***
	Town	4790(25.8)	694(27.4)	4096(25.5)
	Urban	4456(24.0)	708(27.9)	3748(23.4)
Left-behind experiences	Yes c	2664(14.3)	464(18.3)	2200(13.7)	χ2 = 37.56***
Single child status	Yes	4018(21.6)	648(25.6)	3370(21.0)	χ2 = 26.81***
Father’s education	Primary school or below	3427(18.4)	445(17.6)	2982(18.6)	χ2 = 47.88***
	Junior high school	8690(46.8)	1076(42.4)	7614(47.5)
	Senior high school	4120(22.2)	601(23.7)	3519(21.9)
	College or above	2341(12.6)	413(16.3)	1928(12.0)
Mother’s education	Primary school or below	4022(21.6)	487(19.2)	3535(22.0)	χ2 = 57.88***
	Junior high school	8904(47.9)	1130(44.6)	7774(48.5)
	Senior high school	3652(19.7)	553(21.8)	3099(19.3)
	College or above	2000(10.8)	365(14.4)	1635(10.2)
Family economic status	Good	839(4.5)	133(5.2)	706(4.4)	χ2 = 14.33**
	Fair	13,605(73.2)	1779(70.2)	11,826(73.7)
	Poor	4134(22.3)	623(24.6)	3511(21.9)
Chronic physical illness	Yes d	488(2.6)	104(4.1)	384(2.4)	χ2 = 25.00***
Family history of mental disorders	Yes	226(1.2)	48(1.9)	178(1.1)	χ2 = 11.20**
Depression	Yes	2284(12.3)	794(31.3)	1490(9.3)	χ2 = 985.65***
Anxiety	Yes	1893(10.2)	722(28.5)	1171(7.3)	χ2 = 1073.31***
Suicide risk	No	16,805(90.5)	2041(80.5)	14,764(92.0)	χ2 = 372.20***
	Suicidal ideation	1382(7.4)	421(16.6)	961(6.0)
	Suicide attempts	391(2.1)	73(2.9)	318(2.0)

EDs, Eating disorders calculated using the EDE-QS, with a clinical cut-off score of 13

^aHan is the major ethnic group in China

^bNot current married included separated, divorced, and widowed

^cLive separately from one or both parents for > 6 months before 16 years

^dChronic physical conditions referred to having at least one of arthritis, angina, asthma, diabetes, visual impairment, or hearing problems

^*p < 0.05, ^** p < 0.01, ^*** p < 0.001, bold type denotes statistical significance

In this study, the prevalence of EDs was 13.6% (2535/18578) among college students. A total of 12.3% (2284/18578) and 10.2% (1893/18578) of participants had depression and anxiety, respectively. As shown in Fig. 1, 9.5% (1773/18578) of college students reported suicide risk, comprising 7.4% (1382/18578) with suicidal ideation and 2.1% (391/18578) with suicide attempts.

Factors associated with EDs

Table 1 also presents the differences in sample characteristics and clinical variables between participants with (n = 2535) and without EDs (n = 16043). Univariate analysis showed that compared with participants without EDs, those with EDs reported a higher prevalence of depression (31.3% vs. 9.3%), anxiety (28.5% vs. 7.3%), suicidal ideation (16.6% vs. 6.0%), and suicide attempts (2.9% vs. 2.0%).

As shown in Table 2, participants with higher BMI (OR = 1.04, 95% CI = 1.03–1.05), residence in town (OR = 1.19, 95% CI = 1.07–1.33) or urban areas (OR = 1.26, 95% CI = 1.12–1.43), left-behind experiences (OR = 1.17, 95% CI = 1.03–1.33), maternal education at senior high school (OR = 1.27, 95% CI = 1.08–1.48) or college or above (OR = 1.32, 95% CI = 1.09–1.61), depression (OR = 2.21, 95% CI = 1.91–2.55), anxiety (OR = 2.54, 95% CI = 2.19–2.96), as well as suicidal ideation (OR = 1.53, 95% CI = 1.33–1.77) and suicide attempts (OR = 1.56, 95% CI = 1.19–2.04) were associated with a higher risk of EDs.

Table 2.

Multivariate analysis for variables associated with EDs (n = 18578)

Eds: Eating disorders

Bold type indicates a significant odds ratio

Additionally, we classified EDs based on a cutoff score of 15 or higher on the EDE-QS and then conducted sensitivity analyses. According to this criterion, the prevalence of EDs among college students was 10.1% (1876/18578; see Supplementary Material 1: Appendix Table 1). EDs were significantly associated with suicidal ideation (OR = 1.46, 95% CI = 1.24–1.71) and suicide attempts (OR = 1.91, 95% CI = 1.44–2.55) after controlling for covariates (see Supplementary Material 1: Appendix Table 2).

Factors associated with suicide risk in participants with EDs

Table 3 compares the sample characteristics, depression, and anxiety of participants with EDs (n = 2535), those with suicide risk (n = 494) and those without suicide risk (n = 2041). Multivariate analysis showed that left-behind experiences (OR = 1.39, 95% CI = 1.07–1.81), chronic physical illness (OR = 1.77, 95% CI = 1.23–2.78), family history of mental disorders (OR = 2.11, 95% CI = 1.10–4.04), depression (OR = 2.02, 95% CI = 1.53–2.66), and anxiety (OR = 2.40, 95% CI = 1.81–3.18) were risk factors for suicide risk among participants with EDs. Older age appeared to be a protective factor against suicide risk in these individuals (OR = 0.84, 95% CI = 0.79–0.90; see Table 4).

Table 3.

Sample characteristics and clinical variables between EDs participants with and without suicide risk [n(%), n = 2535]

Variables		With SB (n = 494)	Without SB (n = 2041)	p-value
Age, years	M(SD)	19.65(1.66)	20.06(1.65)	t =−5.01 ***
Body mass index	M(SD)	24.47(6.25)	25.23(7.78)	t =−2.29 *
	< 18.5 [underweight]	37(7.5)	166(8.1)	χ2 = 4.44
	18.5–23.9 [normal weight]	263(53.2)	979(48.0)
	≥ 24 [overweight/obesity]	194(39.3)	896(43.9)
Sex	Male	172(34.8)	713(34.9)	χ2 = 0.002
	Female	322(65.2)	1328(65.1)
Ethnicity	Han	482(97.6)	1995(97.7)	χ2 = 0.06
	Others	12(2.4)	46(2.3)
Parental marital status	Married	440(89.1)	1848(90.5)	χ2 = 0.98
	Not current married	54(10.9)	193(9.5)
Residence location	Rural	215(43.5)	918(45.0)	χ2 = 1.26
	Town	131(26.5)	563(27.6)
	Urban	148(30.0)	560(27.4)
Left-behind experiences	Yes	124(25.1)	340(16.7)	χ2 = 18.96***
Single child status	Yes	131(26.5)	517(25.3)	χ2 = 0.30
Father’s education	Primary school or below	96(19.4)	349(17.1)	χ2 = 1.86
	Junior high school	202(40.9)	874(42.8)
	Senior high school	113(22.9)	488(23.9)
	College or above	83(16.8)	330(16.2)
Mother’s education	Primary school or below	93(18.8)	394(19.3)	χ2 = 0.71
	Junior high school	224(45.3)	906(44.4)
	Senior high school	66(13.4)	442(21.7)
	College or above	66(13.4)	299(14.6)
Family economic status	Good	25(5.1)	108(5.3)	χ2 = 7.58*
	Fair	324(65.6)	1455(71.3)
	Poor	145(29.4)	478(23.4)
Chronic physical illness	Yes	34(6.9)	70(3.4)	χ2 = 12.05***
Family history of mental disorders	Yes	17(3.4)	31(1.5)	χ2 = 7.91**
Depression	Yes	272(55.1)	522(25.6)	χ2 = 160.74***
Anxiety	Yes	260(52.6)	462(22.6)	χ2 = 175.68***

^*p < 0.05, ^** p < 0.01, ^*** p < 0.001, bold type denotes statistical significance

Table 4.

Multivariate analysis for variables associated with suicide risk among participants with EDs (n = 2535)

EDs: Eating disorders

Bold type indicates a significant odds ratio

Discussion

In our study, using a cutoff score of 13 or higher on the EDE-QS as the screening criterion, the prevalence of EDs over a one-week period was 13.6% among college students, which was similar to the results of a previous study conducted on Malaysian college students in the US (13.9%) [12]. However, our prevalence rates were higher than those of a previous large-scale survey of U.S. college students (7.15%) [11] but lower than those from a small sample of college students in Saudi Arabia (27.1%) [13]. The discrepant findings may be attributed to variations in samples and assessment methods.

Our findings indicated that participants whose residence location was in town/urban areas reported a higher prevalence of EDs relative to those from rural areas, which is consistent with prior studies [52, 53]. One possible reason is that urbanization intensifies the thin ideal and distorts body weight perception, resulting in increased body dissatisfaction and weight control behaviors [54]. Urbanization also affects food resources, availability, food security, and dietary intake, all of which may increase the risk of EDs [54]. Meanwhile, left-behind experiences were associated with ED risk among college students, albeit weakly. One previous survey of Romanian female adolescents found no significant effect of parental migration on EDs [55], whereas studies in Chinese populations have reported higher prevalence rates of EDs among left-behind adolescents compared to non-left-behind peers [56, 57]. A plausible explanation is that individuals with left-behind experiences tend to report higher levels of loneliness [58], thereby exacerbating their engagement in unhealthy eating behaviors [59]. We also found that the higher the maternal education level, the higher the risk of eating disorders among participants, which is in line with previous studies [60, 61]. As primary caregivers, mothers with higher educational attainment tend to impose elevated academic and behavioral standards on their children. Such expectations may translate into heightened psychological stress, thereby increasing vulnerability to ED symptoms. Additionally, this finding echoes those reported in previous studies [13, 62], which showed that individuals with a higher BMI may be at elevated risk of EDs. Those with a higher BMI may experience more severe body dissatisfaction, which in turn leads to disordered eating behaviors [63]. Although a small number of studies have confirmed that low BMI may also increase the risk of EDs [64], the notion that “thinner is better” is widely endorsed among Chinese college students. Underweight individuals, particularly women, tend to report higher body shape satisfaction [65], which may partially mitigate their risk of developing EDs.

Our data showed that college students with depression and anxiety are more than twice as likely to have EDs. A study by Strid et al. [66] involving 3425 college students in Sweden indicated that EDs were associated with depressive and anxiety symptoms. Other studies conducted in various countries, such as China [67], the United Kingdom [21], and Mexico [16], further confirmed the relationship between EDs and affective symptoms. We also found that college students with EDs remained at higher risk for suicidal ideation and suicide attempts after controlling for depression and anxiety, which is consistent with prior findings that EDs are independently associated with suicide risk [68]. Grounded in the interpersonal-psychological theory of suicide [69, 70], individuals with EDs demonstrate a markedly elevated acquired capability for suicide. Specifically, habitual starvation and painful and provocative eating behaviors—such as self-induced vomiting and laxative misuse—increase pain tolerance and reduce fear of death. Additionally, shared genetic susceptibilities may further explain the specificity of the EDs–suicide risk association, which remains independent of other comorbid psychopathologies, including depression and anxiety [71].

The present study further examined influential factors related to suicide risk among college students with EDs. Younger students were at higher risk of suicide, consistent with prior findings among Chinese college students [72], possibly because they are still adapting to college life [73]. This finding replicates earlier research [74, 75], in which both left-behind experiences and chronic physical illness showed low-to-moderate associations with elevated suicide risk. Notably, family history of mental disorders has been identified as a significant risk factor for suicide risk among participants with EDs, conferring a twofold increase in suicide risk. A recent meta-analysis of 33 studies also revealed that family history of mental disorders represents an important risk factor for suicidality among college students [76]. In addition, the multivariate model identified depression and anxiety as strong correlates of suicide risk among college students with EDs, which is consistent with previous studies [77]. Given the high comorbidity between EDs, depression, and anxiety [66], reducing co-occurring mood symptoms among college students with EDs may also have the added benefit of reducing suicide risk.

Implications

The findings of our study indicate that EDs are prevalent among Chinese college students, highlighting the need for increased awareness and prevention efforts. Understanding the prevalence and correlates of EDs holds significant implications for educators and clinicians. This study identified specific subgroups at elevated risk for EDs, including individuals with elevated BMI, those residing in urban or town areas, and left-behind students. Participants with these characteristics may be primary targets for ED interventions. Furthermore, given the strong link between EDs and suicide risk, we strongly recommend that ED interventions incorporate concurrent assessment of suicidality. Intervention strategies should target co-occurring depressive and anxiety symptoms to mitigate suicidality among affected individuals.

Strengths and limitations

Although this study has several strengths, including a large sample of college students and comprehensive examination of multiple influential factors, several limitations warrant attention. First, the cross-sectional design precludes causal inference; therefore, longitudinal studies are needed to establish causal relationships between EDs and suicide risk. Second, EDs, depression, anxiety, and suicide risk were assessed via self-report measures, which may be susceptible to reporting biases stemming from social desirability and recall bias. In particular, depression, and anxiety were each measured using a limited number of items. Although these brief instruments have demonstrated acceptable psychometric properties in the Chinese cultural context, such brevity may have somewhat limited measurement precision. Suicide risk was screened using the 3ST model, where the determination of suicide attempts was based on indirect inferences drawn from the assessment of suicide capability. Therefore, the results regarding suicide risk should be interpreted with caution, and future research should employ more standardized measurement tools or clinical interviews to enhance the validity of the findings. Meanwhile, to mitigate potential confounding by psychiatric conditions, we assessed participants’ history of mental disorders through self-report and excluded these individuals from the analysis. However, some participants may have concealed their true condition due to stigma, potentially introducing bias into the results. Future research should incorporate clinical interviews or objective assessments to obtain more accurate evaluations of these conditions. Furthermore, given that participants were recruited via convenience sampling from four colleges/universities, caution is warranted when generalizing these findings to the broader national population. Future studies should seek to validate these findings in more representative samples. Finally, the EDE-QS is a screening tool for probable EDs and does not permit formal diagnosis. Because the EDE-QS is typically regarded as a unidimensional screening tool for assessing the overall severity of EDs, future research would benefit from drawing more nuanced distinctions among ED presentations (e.g., binge eating and purging behaviors). Examining associations between specific ED dimensions and the suicidal spectrum would significantly extend the current findings and provide highly meaningful insights for the field.

Conclusion

This study demonstrated that EDs are prevalent among Chinese college students. Notably, individuals with EDs exhibited a significantly elevated risk of suicidal ideation and suicide attempts. These findings underscore the importance of screening college students for ED symptoms while closely monitoring suicide risk in this population. Intervention strategies should focus on co-occurring depressive and anxiety symptoms to reduce suicidality among affected individuals.

Supplementary Information

Supplementary Material 1 ^{(30.8KB, docx)}

Author contributions

Jiaxing Wang: Conceptualization; Methodology; Formal analysis; Investigation; Writing-original draft preparation. Yukai Li: Methodology; Formal analysis; Writing-review & editing. Chengjing Wu: Validation; Writing-review & editing. Dongfang Wang: Conceptualization; Investigation; Project administration; Resources; Supervision; Validation; Writing- review & editing.

Funding

This study was funded by the Guangdong Basic and Applied Basic Research Foundation (2026A1515011803), Guangdong Police College Institutional Project-Organized Scientific Research Breakthrough Initiative (2025SYZ06), Research Center for Brain Cognition and Human Development, Guangdong, China (2024B0303390003), MOE (Ministry of Education in China) Major Project of Philosophy and Social Sciences Research (2025JZDZ024), Psychological services and counselling bases for the Happy Guangzhou project, which received funding from the Guangzhou government, and Striving for the First-Class, Improving Weak Links and Highlighting Features (SIH) Key Discipline for Psychology in South China Normal University.

Data availability

The data that support the findings of this study are available on request from the corresponding author.

Declarations

Ethics approval and consent to participate

All procedures performed in this study were in accordance with the Helsinki Declaration and its later amendments. Electronic informed consent was obtained from all participants and their legal guardians (for participants under 18 years of age). This study was approved by the Ethics Committees of School of Psychology, South China Normal University (approval number: SCNU-PSY-2023-345).

Competing interests

The authors declare no competing interests.