Background
Unhealthy behaviors are associated with mental health problems and violence in adolescents, yet their combined association has been understudied. Using the Global School Health Survey, this study examined the association between combined unhealthy behaviors (including fast food, soft drink, smoking, other tobacco products and physical inactivity) and anxiety, suicidal ideation and involvement in physical fight among Pakistani adolescents.

Methods
Data were obtained from the Global School Health Survey conducted in Pakistan (2009). The study population consisted of school going adolescents aged 13 to 15 years. Association of combined unhealthy behaviors with anxiety, suicidal ideation and involvement in physical fight were studied through secondary analysis. We used univariate and multivariate logistic regression analysis by complex sample method, accounting for cluster sampling technique used for data collection.

Results
Of the total 4583 students, weighted percentage and unweighted count for one, two, three and four or more unhealthy behaviors was 39.4% (n?=?1770), 22.1% (n?=?963), 5.9% (n?=?274) and 1.2% (n?=?62) respectively. The weighted prevalence for anxiety, suicidal ideation and involvement in physical fight were 8.4%, 7.3% and 37.4% respectively. The results of multivariate logistic regression analysis after adjustment showed that students who had four or more unhealthy behaviors had higher odds of; being anxious (OR 2.45, 95%CI 1.31-4.59, p value 0.004), suicide ideation (OR 4.56, 95%CI 2.58-8.07, p value <0.001) and being involved in physical fight (OR 3.15, 95% CI 1.63–6.08, p value <0.001) as compared to those who had not adopted any unhealthy behaviors.

Conclusions
This study suggests that the co-occurrence of unhealthy behaviors is associated with anxiety, suicidal ideation and physical fight among adolescents. These findings should be considered when developing interventions to combat detrimental outcomes of unhealthy behaviors during adolescence.