Relationship between individual categories of adverse childhood experience and diabetes in adulthood in a sample of US adults: Does it differ by gender?
Introduction
In 2012, an estimated 3.4 million children in the United States (U.S.) were reported as having experienced some form of adverse childhood experience (ACE).1 These include acts of commission (physical, emotional, or sexual abuse) and acts of omission (neglect and parental absence).1 ACEs not only impact the normative development process but also confer greater risk for poor health outcomes in adulthood.2., 3. Since the development of the ACE scale, multiple studies have shown that ACEs are strong risk factors for poor health outcomes throughout the lifespan as well as for many of the leading causes of death in the U.S.3., 4.
Diabetes is a major public health concern and has been linked to the occurrence of ACEs.5., 6., 7., 8., 9., 10. Diabetes affects > 29 million people and is the seventh leading cause of death in the U.S.11 It is associated with many comorbid conditions including heart disease, stroke, and kidney disease.11 In addition to the burden of disease, the direct and indirect costs of diabetes exceed $240 billion in the U.S. and are expected to increase as burden of disease increases.11 The relationship between ACEs and diabetes is believed to be cumulative, with diabetes risk increasing as the number of ACEs increases.4., 5., 8., 9., 12. Evidence suggests that individuals who report ACEs have on average a 32% higher odds of diabetes in adulthood compared to those who do not report ACEs,13 and experiencing ACEs repeatedly throughout childhood may increase the odds of diabetes in adulthood by 49%.6 In addition to this dose-response relationship, type of ACE has been implicated in risk for diabetes in adulthood as well.5., 6., 14., 15. However, there has been no comprehensive analysis of the different categories and the impact on diabetes accounting for important covariates in a single population.
Gender is also suggested to be an important factor when looking at the impact of ACEs, however findings have been mixed.16., 17. For instance, a longitudinal examination of the differential impact of childhood abuse on adult health found that repeated exposure to sexual abuse was associated with increased risk of diabetes in men only.16 Whereas, Gonzalez et al. found that the relationship between depression, chronic pain, and diabetes was lower for males than for females.18 In contrast, a recent meta-analysis found that among cohort and cross-sectional studies assessing ACEs and diabetes, parental neglect served as the strongest predictor of diabetes, and did not differ between men and women.13 The difference in findings may be due to inconsistent and narrow definitions of ACEs such as only assessing one type of ACE or restricting events experienced to a caregiver only, not accounting for events that may have occurred by non-caregivers16 as well the variation in study designs.19
Overall, the literature suggests that individual ACE components may have a differential impact on risk of diabetes, and that this impact may be gender specific. This study aims to add to the knowledge base on these topics by examining: (1) the differential relationship between individual ACE components and self-reported diabetes in adulthood; and (2) investigating the relationship between eight categories of ACEs and self-reported diabetes in adulthood by gender in a national dataset using a previously validated scale.
Section snippets
Material and methods
Data from the 2011 Behavioral Risk Factor Surveillance System (BRFSS) survey, a cross-sectional telephone survey using random-digit dialing to landline and cellular telephones, was used in this study.20 BRFSS survey participants include a total of 506,467 non-institutionalized U.S. adults ages 18 years and older. A total of 48,526 participants completed the ACE module across 5 states, including Minnesota, Montana, Vermont, Washington and Wisconsin. To achieve nationally representative estimates,
Results
Table 1 shows sample characteristics by diabetes status for the subsample of participants that were asked the ACE questions. Among participants, the majority were age 35–54. Approximately 83% were white and 33% had some college. There was a statistically significant difference in demographics across diabetes status, except for gender.
Table 2 shows the relationship between individual ACE categories and diabetes status. Approximately 34% of participants with diabetes experienced verbal abuse and
Discussion
In this analysis using a national dataset, we found that after adjusting for important demographic characteristics, the odds of diabetes were higher for individuals who experienced sexual abuse, verbal abuse, physical abuse, and having a parent with mental illness. Sexual abuse was the strongest predictor of increased odds of diabetes, with individuals reporting sexual abuse having a 57% higher likelihood of diabetes compared to those who did not report sexual abuse. The relationship between
Limitations
This study has some limitations that should be noted. The BRFSS does not allow for differentiation by diabetes type, as such the assessment of type 2 diabetes is not specific. However, CDCs prevalence estimates of diabetes report that 95% of the diabetes population are those with T2DM, therefore use of this BRFSS variable to estimate T2DM prevalence is reasonable. Secondly, this analysis used self-report measures which may be impacted by participant recall bias; however, the literature supports
Conclusion
In conclusion, this study found that after adjusting for relevant socio-demographic factors known to confound the relationship with diabetes, four separate ACE categories were statistically significantly associated with increased odds of diabetes in adulthood. Sexual abuse served as the strongest predictor, followed by verbal and physical abuse, and having a parent with mental illness. Results did not show a gender specific relationship between ACE category and odds of diabetes. These findings
Funding
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (Grant K24DK093699, principal investigator LE).
Authors' contributions
JC was a major contributor in writing and interpreting the manuscript. LE analyzed and interpreted the data in this manuscript. GF and SNR were major contributors in writing the manuscript. RW was a major contributor in interpreting the data in this manuscript. All authors read and approved the final manuscript.
References (29)
- et al.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experience study
Am J Prev Med
(1998) Adverse childhood experiences and adult health
Acad Pediatr
(2009)- et al.
Associations between adverse childhood experiences, high risk behaviors, and morbidity in adulthood
Am J Prev Med
(2016) - et al.
Abuse in childhood and adolescence as a predictor of type 2 diabetes in adult women
Am J Prev Med
(2010) - et al.
Adverse childhood experiences and risk of type 2 diabetes: a systematic review and meta-analysis
Metabolism
(2015) - et al.
Inflammation and early-life abuse in women
Am J Prev Med
(2012) - et al.
The association between number and type of traumatic life experiences and physical conditions in a nationally representative sample
Gen Hosp Psychiatry
(2014) - et al.
Diminished cortisol responses to psychosocial stress associated with lifetime adverse events: a study among healthy young subjects
Psychoneuroendocrinology
(2008) - et al.
Childhood and family influences on depression, chronic physical conditions, and their comorbidity: findings from the Ontario Child Health Study
J Psychiatr Res
(2012) - et al.
Sex differences in HPA axis responses to stress: a review
Biol Psychol
(2005)
Reliability and changes in validity of self-reported cardiovascular disease risk factors using dual response: the behavioral risk factor survey
J Clin Epidemiol
Childhood trauma and adulthood inflammation: a meta-analysis of peripheral C-reactive protein, interleukin-6 and tumour necrosis factor-A
Mol Psychiatry
Childhood Adversities and Adult Cardiometabolic Health: does the quantity, timing, and type of adversity matter?
J Aging Health
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2020, Endocrine PracticeCitation Excerpt :Many of these studies grouped type 1 and type 2 into one diabetes group, similar to ours. One study found that experiencing sexual abuse during childhood showed the highest odds of having a diabetes diagnosis (type 1 or type 2) when compared to other forms of abuse such as parenteral incarceration, witnessing adult violence, and adult substance abuse (19). Verbal abuse, physical abuse, and parental mental illness also specifically increased the odds of diabetes.
Conflict of interest: Authors report no conflict of interest.