Disparities in Behaviors and Experiences Among Transgender and Cisgender High School Students - 18 U.S. States, 2021.

PURPOSE: Transgender youths (those whose gender identity differs from their sex assigned at birth) experience stigma and discrimination that can place them at increased risk for poor health outcomes compared with cisgender youths (those whose gender identity aligns with their sex assigned at birth). Limited population-based data exist on disparities among transgender and cisgender youths. METHODS: We examined differences in experiences of violence, substance use, mental health, suicide, sexual behavior, unstable housing, parental monitoring, and school connectedness among 98,174 transgender and cisgender high school students using data from 18 states that included an item to assess transgender identity on their 2021 Youth Risk Behavior Survey. RESULTS: Overall, 2.9% of students identified as transgender and 2.6% questioned whether they were transgender. Among transgender students, 71.5% reported that their mental health was not good, 32.3% had attempted suicide, and 29.0% experienced sexual violence. Transgender students were more likely than cisgender students to report experiences of violence, substance use, poor mental health, suicide risk, some sexual risk behaviors, and unstable housing, and were less likely to report feeling connected to others at school. CONCLUSIONS: Interventions that can address the causes of these adverse outcomes and promote the health and wellbeing of transgender youths are warranted.

Resilience to periodic disturbances and the long-term genetic stability in Acropora coral.

Climate change is restructuring natural ecosystems. The direct impacts of these events on biodiversity and community structure are widely documented, but the impacts on the genetic variation of populations remains largely unknown. We monitored populations of Acropora coral on a remote coral reef system in northwest Australia for two decades and through multiple cycles of impact and recovery. We combined these demographic data with a temporal genetic dataset of a common broadcast spawning corymbose Acropora to explore the spatial and temporal patterns of connectivity underlying recovery. Our data show that broad-scale dispersal and post-recruitment survival drive recovery from recurrent disturbances, including mass bleaching and mortality. Consequently, genetic diversity and associated patterns of connectivity are maintained through time in the broader metapopulation. The results highlight an inherent resilience in these globally threatened species of coral and showcase their ability to cope with multiple disturbances, given enough time to recover is permitted.

Reliability of the 2021 National Youth Risk Behavior Survey Questionnaire.

PURPOSE: The Youth Risk Behavior Survey (YRBS) monitors behaviors, experiences, and conditions affecting the health of high school students nationwide. This study examined the test-retest reliability of the 2021 national YRBS questionnaire. DESIGN: Respondents completed a Time 1 and Time 2 paper-and-pencil questionnaire approximately 2 weeks apart during February to May 2022. Data were linked in such a way as to preserve anonymity. SETTING: Convenience sample of high schools. SUBJECTS: High school students (N = 588). MEASURES: Health risk behaviors and experiences assessed on the 2021 national YRBS questionnaire. ANALYSIS: Time 1 and Time 2 responses were compared for each questionnaire item using the McNemar's test. Then, Cohen's kappa coefficients tested the agreement between Time 1 and Time 2 responses overall, and by sex, grade, and Black, White, and Hispanic race and ethnicity. RESULTS: Among the 74 items analyzed, 96% had at least moderate reliability, and 73% had substantial or almost perfect reliability. The mean Cohen's kappa was .68. McNemar's test findings showed Time 1 and Time 2 data significantly differed (P < .01) for 9 items (12%). CONCLUSION: Reliable health behavior measures are important in the development of youth-focused public health programs and policies. Findings suggest the national YRBS questionnaire is a reliable instrument. Such findings lend support to relying on adolescent self-reported data when monitoring health behaviors using the YRBS.

Reliability of the 2020 School Health Profiles Principal and Lead Health Education Teacher Questionnaires.

BACKGROUND: School Health Profiles assesses school health policies and practices among US secondary schools. METHODS: The 2020 School Health Profiles principal and teacher questionnaires were used for a test-retest reliability study. Cohen's kappa coefficients tested the agreement in dichotomous responses to each questionnaire variable at 2 time points. The aggregate prevalence estimates between time 1 and time 2 were compared for each questionnaire item via overlapping 95% confidence intervals. Chi-square tests examined whether the prevalence at time 2 differed between paper and web administration for both questionnaires. RESULTS: For the principal (N = 50) and teacher (N = 34) data, there were no significant differences in the prevalence of any items between time 1 and time 2. For the principal survey, the mean kappa for 191 variables was 0.49. For the teacher survey, the mean kappa for 260 variables was 0.65. Overall, 60.7% of principal and 91.1% of teacher questionnaire items had at least "moderate" reliability. CONCLUSIONS: School Health Profiles offers education and health agencies a reliable tool to monitor school policies and practices.

Overview and Methods for the Youth Risk Behavior Surveillance System - United States, 2021.

The Youth Risk Behavior Surveillance System (YRBSS) is the largest public health surveillance system in the United States, monitoring a broad range of health-related behaviors among high school students. The system includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate school-based YRBSs conducted by states, tribes, territories, and local school districts. In 2021, these surveys were conducted during the COVID-19 pandemic. The pandemic underscored the importance of data in understanding changes in youth risk behaviors and addressing the multifaceted public health needs of youths. This overview report describes 2021 YRBSS survey methodology, including sampling, data collection procedures, response rates, data processing, weighting, and analyses. The 2021 YRBS participation map, survey response rates, and a detailed examination of student demographic characteristics are included in this report. During 2021, in addition to the national YRBS, a total of 78 surveys were administered to high school students across the United States, representing the national population, 45 states, two tribal governments, three territories, and 28 local school districts. YRBSS data from 2021 provided the first opportunity since the onset of the COVID-19 pandemic to compare youth health behaviors using long-term public health surveillance. Approximately half of all student respondents represented racial and ethnic minority groups, and approximately one in four identified as lesbian, gay, bisexual, questioning, or other (a sexual identity other than heterosexual) (LGBQ+). These findings reflect shifts in youth demographics, with increased percentages of racial and ethnic minority and LGBQ+ youths compared with previous YRBSS cycles. Educators, parents, local decision makers, and other partners use YRBSS data to monitor health behavior trends, guide school health programs, and develop local and state policy. These and future data can be used in developing health equity strategies to address long-term disparities so that all youths can thrive in safe and supportive environments. This overview and methods report is one of 11 featured in this MMWR supplement. Each report is based on data collected using methods presented in this overview. A full description of YRBSS results and downloadable data are available (https://www.cdc.gov/healthyyouth/data/yrbs/index.htm).

Experiences of Unstable Housing Among High School Students - Youth Risk Behavior Survey, United States, 2021.

Youths experiencing unstable housing face higher risks for poor physical, mental, and sexual health outcomes and increased risk for suicide compared with their peers experiencing stable housing. In addition, youths of color and sexual minority youths are disproportionately more likely to experience homelessness. For the first time, in 2021, the nationally representative Youth Risk Behavior Survey included an item assessing housing stability, or nighttime residence among students in grades 9-12 in the United States. During 2021, 2.7% of U.S. high school students experienced unstable housing. Among racial and ethnic subgroups, Native Hawaiian or other Pacific Islander youths were most likely to experience unstable housing, followed by American Indian or Alaska Native and Black youths. Sexual minority (lesbian, gay, bisexual, and questioning or other) youths were more likely to experience unstable housing compared with their heterosexual peers. Compared with students who were stably housed, students who were unstably housed were more likely to engage in risky sexual behaviors, substance use, and suicide ideation and attempts, and to experience violence. These findings highlight which adverse health risks and behaviors are elevated among youths experiencing housing insecurity. Focused public health interventions are required to address the disproportionate burden of health risks prevalent among youths who are unstably housed.

Health-Risk Behaviors and Experiences Among Asian American and Native Hawaiian/Pacific Islander Adolescents in the United States, 2011-2019.

OBJECTIVES: Understanding the health-risk behaviors of racial and ethnic groups when disaggregated is an important step in improving the health outcomes of racial and ethnic minority groups. We compared national prevalence estimates for selected health-risk behaviors and experiences of Asian American and Native Hawaiian/Pacific Islander (NHPI) students with those of non-Hispanic White, non-Hispanic Black, and Hispanic students. METHODS: We analyzed data from the Youth Risk Behavior Survey, a nationally representative survey of US high school students. To generate a sufficient sample of Asian American and NHPI students for analyses, we combined data from 5 survey administrations, conducted in 2011, 2013, 2015, 2017, and 2019 (N = 73 074). We calculated the prevalence and 95% CIs; we analyzed data on Asian American and NHPI adolescents separately to unmask important differences. RESULTS: Compared with students of other races and ethnicities, Asian American students had the lowest prevalence of alcohol use (16.7%) and marijuana use (10.3%). In contrast, NHPI students were more likely than Asian American students to participate in several health-risk behaviors and experiences, such as substance use (ranging from 4.8% for ever injecting an illegal drug to 31.5% for current alcohol use), having been in a physical fight (15.4%), and having been threatened or injured with a weapon (11.6%). Differential patterns in the prevalence of ever having missed school due to feeling unsafe among NHPI and Asian American students were observed among male and female students. CONCLUSION: Further disaggregating racial subgroups within broad categories of Asian American and NHPI populations may reveal differences from overall group prevalence, and additional strategies to identify these differences should be investigated.

Prolonged Periods of Antegrade Cerebral Perfusion Are Safe During Elective Arch Surgery.

BACKGROUND: Cerebral circulatory arrest times >40 minutes during aortic surgery have previously been shown to be associated with increased morbidity and mortality. The purpose of this study was to redefine what would constitute a safe period of circulatory arrest for patients who underwent elective proximal aortic operations requiring antegrade cerebral perfusion (ACP). METHODS: The ARCH International aortic database was queried, and 2008 patients undergoing elective arch operations with circulatory arrest using ACP were identified. Circulatory arrest time was categorized a priori in 10-minute intervals. To further determine the impact of this variable on outcomes, hierarchical multivariable regression analysis was performed. RESULTS: Unadjusted mortality increased with increasing circulatory arrest time from 4.8% (<40 minutes) to 13.5% (>90 minutes; P < .001), but risk of stroke was not impacted (P = .4). When treated as a continuous variable, mortality increased significantly with increasing circulatory arrest time, whereas the risk of permanent stroke did not. Using <40 minutes as the reference, multivariable analysis showed no statistical increase in mortality for ranges up to 80 minutes of circulatory arrest. The risk of permanent stroke was not significantly higher for any time interval >40 minutes up to 90 minutes. CONCLUSIONS: In this series of patients who underwent elective proximal aortic surgery using ACP, periods of circulatory arrest up to at least 80 minutes were not associated with significant increases in mortality or permanent stroke. Modern perfusion strategies have allowed for increased safety during elective arch cases requiring prolonged periods of circulatory arrest.

Racial-ethnic disparities in adolescent sexual behaviours: the cross-sectional Youth Risk Behavior Survey, 2009–19.

BACKGROUND: There are notable disparities by race/ethnicity in the sexual health of US adolescents and young adults. Our objective was to examine change over time in racial-ethnic disparities in sexual behaviours among US high school students. METHODS: Data were analysed from six biennial cycles of the national Youth Risk Behavior Survey (2009-19), conducted among cross-sectional, nationally representative samples of 9th-12th grade students. Data were collected via self-administered questionnaires. Multivariable logistic regression models tested for linear trends by race/ethnicity (White, Black, Hispanic) and differences in these trends in: ever had sex, current sexual activity, having four or more lifetime sexual partners, and condomless sex. Prevalence ratios and risk differences by race/ethnicity for each cycle were used to calculate average percent change in the estimates to determine if health disparities changed over time. RESULTS: During 2009-19, prevalence estimates for ever had sex, current sexual activity, and having four or more lifetime sexual partners decreased overall and across all racial-ethnic groups. For condomless sex, prevalence estimates increased over time overall (38.9-45.7%) and for Black (37.6-51.8%) and White (36.7-44.2%) students, but not Hispanic (45.1-43.8%) students. Significant differences in trends by race/ethnicity were observed for all variables. Data suggest that racial-ethnic health disparities for sexual behaviours decreased over time, except for condomless sex. CONCLUSIONS: Although racial-ethnic gaps in sexual behaviours may be shrinking for many behaviours, work is still needed to achieve health equity in risks associated with HIV/AIDS, sexually transmitted infections, and pregnancy.

At the Intersections: Examining Trends in Experiences of Violence, Mental Health Status, and Suicidal Risk Behaviors Among US High School Students Using Intersectionality, National Youth Risk Behavior Survey, 2015-2019.

PURPOSE: Surveillance data are used for public health action, but the practice of analyzing data by single demographic characteristics may produce findings that reflect abstract categories rather than a person's lived experience. Intersectionality is a theoretical framework that advocates for individuals to be recognized as the whole of their identity and within context of power structures. Using the national Youth Risk Behavior Survey 2015-2019, we examined 5-year trends in experiencing violence, poor mental health, and suicidal risk behavior among US high school students using intersections of race/ethnicity and sex. METHODS: We used SUDAAN to calculate prevalence estimates and logistic regression models to assess for linear trends while accounting for the weighting and complex survey design. RESULTS: Among all students in aggregate, experiencing dating violence decreased while being threatened with a weapon at school and feeling persistently sad or hopeless increased over time; however, these trends did not apply to most students when stratified by identity. The one near-universal experience was that students in aggregate and almost all identities had an increased trend of skipping school because they felt unsafe there. DISCUSSION: By focusing on identities defined by two main drivers of health disparities-race/ethnicity and sex-we found that changes in risk behaviors did not occur equally among students and that prevalence estimates were highest among Black males, Black females, and Hispanic females. We outlined the power structures that frame the current educational environment. Patterns of health disparities can be highlighted by analyzing surveillance data through an intersectional lens.

Electronic Versus Paper and Pencil Survey Administration Mode Comparison: 2019 Youth Risk Behavior Survey.

BACKGROUND: Since the inception of the Youth Risk Behavior Surveillance System in 1991, all surveys have been conducted in schools, using paper and pencil instruments (PAPI). For the 2019 YRBSS, sites were offered the opportunity to conduct their surveys using electronic data collection. This study aimed to determine whether differences in select metrics existed between students who completed the survey electronically versus using PAPI. METHODS: Thirty risk behaviors were examined in this study. Data completeness, response rates and bivariate comparisons of risk behavior prevalence between administration modes were examined. RESULTS: Twenty-nine of 30 questions examined had more complete responses among students using electronic surveys. Small differences were found for student and school response rates between modes. Twenty-five of 30 adolescent risk behaviors showed no mode effect. CONCLUSIONS: Seven of 44 states and DC participated electronically. Because survey data were more complete; school and student response rates were consistent; and minor differences existed in risk behaviors between modes, the acceptability of collecting data electronically was demonstrated.

Perceived Racism and Demographic, Mental Health, and Behavioral Characteristics Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021.

Perceived racism in school (i.e., a student's report of being treated badly or unfairly because of their race or ethnicity) is an important yet understudied determinant of adolescent health and well-being. Knowing how perceived racism influences adolescent health can help reduce health inequities. CDC's 2021 Adolescent Behaviors and Experiences Survey (ABES), an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9-12 (N = 7,705), was conducted during January-June 2021 to assess student behaviors during the COVID-19 pandemic. CDC analyzed data from ABES to measure perceived racism and the extent to which perceptions of racism are associated with demographic, mental health, and behavioral characteristics. Mental health and behavioral characteristics analyzed included mental health status; virtual connection with others outside of school; serious difficulty concentrating, remembering, or making decisions; and feeling close to persons at school. Demographic characteristics analyzed included sex, race and ethnicity, and grade. Prevalence of perceived racism and associations between perceived racism and demographic, mental health, and behavioral characteristics are reported overall and stratified by race and ethnicity. Approximately one third (35.6%) of U.S. high school students reported perceived racism. Perceived racism was highest among Asian (63.9%), Black (55.2%), and multiracial students (54.5%). Students who reported perceived racism had higher prevalences of poor mental health (38.1%); difficulty concentrating, remembering, or making decisions (44.1%); and not feeling close to persons at school (40.7%). Perceived racism was higher among those students who reported poor mental health than those who did not report poor mental health during the pandemic among Asian (67.9% versus 40.5%), Black (62.1% versus 38.5%), Hispanic (45.7% and 22.9%), and White students (24.5% versus 12.7%). A better understanding of how negative health outcomes are associated with student experiences of racism can guide training for staff and students to promote cultural awareness and antiracist and inclusivity interventions, which are critical for promoting safe school environments for all students.

Disruptions to School and Home Life Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021.

Youths have experienced disruptions to school and home life since the COVID-19 pandemic began in March 2020. During January-June 2021, CDC conducted the Adolescent Behaviors and Experiences Survey (ABES), an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9-12 (N = 7,705). ABES data were used to estimate the prevalence of disruptions and adverse experiences during the pandemic, including parental and personal job loss, homelessness, hunger, emotional or physical abuse by a parent or other adult at home, receipt of telemedicine, and difficulty completing schoolwork. Prevalence estimates are presented for all students and by sex, race and ethnicity, grade, sexual identity, and difficulty completing schoolwork. Since the beginning of the pandemic, more than half of students found it more difficult to complete their schoolwork (66%) and experienced emotional abuse by a parent or other adult in their home (55%). Prevalence of emotional and physical abuse by a parent or other adult in the home was highest among students who identified as gay, lesbian, or bisexual (74% emotional abuse and 20% physical abuse) and those who identified as other or questioning (76% and 13%) compared with students who identified as heterosexual (50% and 10%). Overall, students experienced insecurity via parental job loss (29%), personal job loss (22%), and hunger (24%). Disparities by sex and by race and ethnicity also were noted. Understanding health disparities and student disruptions and adverse experiences as interconnected problems can inform school and community initiatives that promote adolescent health and well-being. With community support to provide coordinated, cross-sector programming, schools can facilitate linkages to services that help students address the adverse experiences that they faced during the ongoing COVID-19 pandemic. Public health and health care professionals, communities, schools, families, and adolescents can use these findings to better understand how students' lives have been affected during the pandemic and what challenges need to be addressed to promote adolescent health and well-being during and after the pandemic.

Overview and Methodology of the Adolescent Behaviors and Experiences Survey - United States, January-June 2021.

Many U.S. schools closed nationwide in March 2020 to prevent the spread of COVID-19. School closures and online-only instruction have negatively affected certain students, with studies showing adverse effects of the pandemic on mental health. However, little is known about other experiences such as economic and food insecurity and abuse by a parent, as well as risk behaviors such as alcohol and drug use among youths across the United States during the pandemic. To address this gap, CDC developed the one-time, online Adolescent Behaviors and Experiences Survey (ABES), which was conducted during January-June 2021 to assess student behaviors and experiences during the COVID-19 pandemic among high school students, including unintentional injury, violence, tobacco product use, sexual behaviors, and dietary behaviors. This overview report of the ABES MMWR Supplement describes the ABES methodology, including the student questionnaire and administration, sampling, data collection, weighting, and analysis. ABES used a stratified, three-stage cluster probability-based sampling approach to obtain a nationally representative sample of students in grades 9-12 attending public and private schools. Teachers of selected classes provided students with access to the anonymous online survey while following local consent procedures. Data were collected using a 110-item questionnaire during January-June 2021 in 128 schools. A total of 7,998 students submitted surveys, and 7,705 of these surveys had valid data (i.e., ≥20 questions answered). The school response rate was 38%, the student response rate was 48%, and the overall response rate was 18%. Information on mode of instruction and school-provided equipment was also collected from all sampled schools. This overview report provides student- and school-level characteristics obtained from descriptive analyses, and the other reports in the ABES MMWR Supplement include information on substance use, mental health and suicidality, perceived racism, and disruptions to student life among high school students. Findings from ABES during the COVID-19 pandemic can help guide parents, teachers, school administrators, community leaders, clinicians, and public health officials in decision-making for student support and school health programs.

Production, metabolism, and follicular dynamics in multiparous dairy cows fed diets providing different amounts of metabolizable protein prepartum and postpartum.

Our objectives were (1) to determine whether increasing metabolizable protein (MP) supply above requirements in late-gestation cows would benefit health, milk production, and reproduction; (2) to determine whether an increased supply of MP postpartum affects production; and (3) to determine whether supply of MP prepartum interacts with MP supply postpartum. Pregnant nonlactating cows (n = 60) blocked by expected parturition date were assigned to 1 of 3 prepartum diets from 21 d prepartum to parturition: 12% crude protein (CP) soybean meal (SBM) supplement (LSB); 15% CP SBM supplement (HSB); and 15% CP SBM plus animal-marine protein supplement (HMP). Diets were formulated to supply an estimated 924, 988, and 1,111 g/d of MP, respectively, at 11.5 kg of dry matter intake (DMI). After parturition, cows received diets containing 18% CP, either from SBM (SB) or SBM plus animal-marine protein (AMP) supplements, that provided 2,056 (SB) or 2,293 g/d (AMP) of MP at 21 kg of DMI; thus, treatments were in a 3 × 2 factorial arrangement. Milk production and DMI were recorded for 63 d postpartum. Prepartum DMI was lower at wk -3 for cows fed LSB compared with those fed HSB or HMP. Postpartum DMI did not differ significantly between cows fed SB and those fed AMP (20.8 vs. 19.6 kg/d). Milk production did not differ due to prepartum diets or postpartum diets. Milk fat and protein percentages were not affected by prepartum or postpartum diets. Cows fed AMP postpartum tended to produce more milk fat, but 4% fat-corrected milk (FCM) did not differ from SB-supplemented cows (33.6 kg/d vs. 32.2 kg/d). Gross feed efficiency (FCM/DMI) was greater for cows fed AMP postpartum (1.82 vs. 1.68). Prepartum concentrations of urea N in plasma were lower for LSB than for HSB and HMP, and HSB was greater than HMP. Postpartum concentrations of nonesterified fatty acids and ß-hydroxybutyrate were greater for cows fed AMP postpartum than for those fed SB. Postpartum urea N was higher for SB than for AMP (14.4 vs. 12.5 mg/dL). Concentration of total protein in plasma was greater postpartum for cows fed HSB or HMP prepartum than for those fed LSB, and was greater postpartum for cows fed AMP than for those fed SB. Hepatic concentrations of total lipids and triglyceride did not differ among treatments. Hepatic glycogen was greater postpartum for cows fed SB postpartum. Feeding HSB or HMP increased the number of follicles 6 to 9 mm in diameter compared with LSB. The size of the largest follicle was increased by HMP compared with HSB. In conclusion, increasing the amount of MP fed to cows during the last 21 d prepartum did not affect milk production or BCS but increased plasma total protein concentration. Follicular dynamics were improved by increasing the amount of MP prepartum. Feeding HMP prepartum improved follicular dynamics prepartum and increased milk fat yield in wk 1. Feeding AMP postpartum increased efficiency of FCM production and plasma total protein. We found few interactions between prepartum and postpartum MP supply.

Risk Behaviors and Experiences Among Youth Experiencing Homelessness-Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts, 2019.

Youth experiencing homelessness experience violence victimization, substance use, suicide risk, and sexual risk disproportionately, compared with their stably housed peers. Yet few large-scale assessments of these differences among high school students exist. The youth risk behavior survey (YRBS) is conducted biennially among local, state, and nationally representative samples of U.S. high school students in grades 9-12. In 2019, 23 states and 11 local school districts included a measure for housing status on their YRBS questionnaire. The prevalence of homelessness was assessed among states and local sites, and relationships between housing status and violence victimization, substance use, suicide risk, and sexual risk behaviors were evaluated using logistic regression. Compared with stably housed students, students experiencing homelessness were twice as likely to report misuse of prescription pain medicine, three times as likely to be threatened or injured with a weapon at school, and three times as likely to report attempting suicide. These findings indicate a need for intervention efforts to increase support, resources, and services for homeless youth.

Individual and Collective Positive Health Behaviors and Academic Achievement Among U.S. High School Students, Youth Risk Behavior Survey 2017.

PURPOSE: We examined associations between academic grades and positive health behaviors, individually and collectively, among U.S. high school students. DESIGN: Cross-sectional study design. SETTING: Data were from the 2017 national Youth Risk Behavior Survey. Response rates were 75% for schools, 81% for students, and 60% overall (n = 14,765 students). SUBJECTS: Youth in grades 9th-12th. MEASURES: We focused on youth behaviors that can prevent or delay the onset of chronic health conditions. Seven dietary, 3 physical activity, 2 sedentary screen time, and 4 tobacco product use behaviors were assessed. Variables were dichotomized (0/1) to indicate that a score was given to the positive health behavior response (e.g.,, did not smoke cigarettes = 1). A composite score was created by summing each positive health behavior response among 16 total health behaviors. ANALYSIS: Multivariable logistic regression analyses for each individual health behavior, and a multivariable negative binomial regression for the composite score, were conducted with self-reported academic grades, controlling for sex, grade in school, race/ethnicity, and body mass index (BMI) categories. RESULTS: Controlling for covariates, students who reported mostly A's had 2.0 (P < .001) more positive health behaviors; students who reported mostly B's had 1.3 (P < .001) more positive health behaviors; and students who reported mostly C's had .78 (P < .001) more positive health behaviors, compared to students who reported mostly D's/F's. CONCLUSIONS: Higher academic grades are associated with more positive individual and cumulative health behaviors among high school students. Understanding these relationships can help inform efforts to create a healthy and supportive school environment and strive for health equity.