Adverse childhood experiences, diabetes and associated conditions, preventive care practices and health care access: A population-based study

Abstract

Our objective was to examine how Adverse Childhood Experiences (ACEs) are associated with diabetes mellitus, diabetes-related conditions, and preventive care practices. We used data from the Behavioral Risk Factor Surveillance System (BRFSS) 2009-2012, a cross-sectional, population-based survey, to assess ACEs, diabetes, and health care access in 179,375 adults. In those with diabetes (n = 21,007), we assessed the association of ACEs with myocardial infarction, stroke, and five Healthy People 2020 (HP2020) diabetes-related preventive-care objectives (n = 13,152). Healthcare access indicators included lack of a regular health care provider, insurance, and difficulty affording health care. Regression analyses adjusted for age, sex, and race. The adjusted odds ratio (AOR) of diabetes increased in a stepwise fashion by ACE exposure, ranging from 1.2 (95% CI 1.1-1.3) for 1 ACE to 1.7 (95% CI 1.6-1.9) for ≥4 ACEs, versus having no ACEs. In persons with diabetes, those with ≥4 ACEs had an elevated adjusted odds of myocardial infarction (AOR = 1.6, 95% CI 1.2-2.0) and stroke (AOR = 1.8, 95% CI 1.3-2.4), versus having no ACEs. ACEs were also associated with a reduction in the adjusted percent of HP2020 diabetes objectives met: 72.9% (95% CI 71.3-74.5) for those with no ACEs versus only 66.5% (95% CI 63.8-69.3%) for those with ≥4 ACEs (p = 0.0002). Finally, ACEs predicted worse health care access in a stepwise fashion for all indicators. In conclusion, ACEs are associated with greater prevalence of diabetes and associated disease conditions, and with meeting fewer HP2020 prevention goals. Implementing ACE screening and trauma-informed health care practices are thus recommended.

Keywords: Access to care; Adverse Childhood Experiences (ACEs); BRFSS; Behavioral Risk Factor Surveillance System; Diabetes; Early adversity; Early life stress; Prevention; Preventive care; Toxic stress.

Fig. 1.. Age-adjusted prevalence and adjusted odds ratios of diabetes and associated conditions by ACE score.

(a) Age adjusted prevalence of diabetes (all participants) and associated disease conditions (participants with diabetes only). The U.S. 2000 population standard was used for age adjustment using the age groups: 18–29, 30–44, 45–54, 55–64, 65–74 and 75 plus. (b) Adjusted odds ratios of diabetes and associated disease conditions for each ACE score as compared to having 0 ACEs. Analyses adjusted for age (continuous), sex, and race/ethnicity. *p < 0.05; **p < 0.01; ***p < 0.001; ^§p < 0.0001.

Fig. 2.. ACE Score and Age-Adjusted Percent Meeting Healthy People 2020 Objectives.

(a) The age-adjusted percent of each ACE score meeting the specified Healthy People 2020 (HP2020) Diabetes Objective. The U.S. 2000 population standard was used for age adjustment using the age groups: 18–29, 30–44, 45–54, 55–64, 65–74, and 75+. The green bars show the target percentage specified in 2010 as the goal for the U.S. population. (b) The mean percent of the five HP2020 objectives met with 95% confidence intervals (CI), adjusted for age (continuous), sex, and race/ethnicity. (Test of ACE effect: p = 0.0031, df = 404, Wald F test).