This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (18)  • Contact me when this article is cited  Related Content  • Related letters  • Similar articles in this journal  Topic Collections  • Child Abuse  • Substance Abuse/ Alcoholism  • Violence and Human Rights  • Violence and Human Rights, Other  • Liver/ Biliary Tract/ Pancreatic Diseases  • Alert me on articles by topic  Social Bookmarking   What's this?

New Insights Into the Causal Pathway

Maxia Dong, MD, PhD; Shanta R. Dube, MPH; Vincent J. Felitti, MD; Wayne H. Giles, MD, MS; Robert F. Anda, MD, MS

Arch Intern Med. 2003;163:1949-1956.

Objective  To examine the relationship of adverse childhood experiences (ACEs), including abuse, neglect, and forms of household dysfunction, to the risk of liver disease by assessing the role of risk behaviors, such as substance abuse and high-risk sexual activity, as mediators of the ACEs–liver disease relationship.

Methods  Retrospective cohort study data were collected from 17 337 adult health plan members through a survey. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACEs–liver disease relationship and the impact of the mediators in this relationship.

Results  Each of 10 ACEs increased the risk of liver disease 1.2 to 1.6 times (P<.001). The number of ACEs (ACE score) had a graded relationship to liver disease (P<.001). Compared with persons with no ACEs, the adjusted odds ratio of ever having liver disease among persons with 6 or more ACEs was 2.6 (P<.001). The ACE score also had a strong graded relationship to risk behaviors for liver disease. The strength of the ACEs–liver disease association was reduced 38% to 50% by adjustment for these risk behaviors, suggesting they are mediators of this relationship.

Conclusions  The ACE score showed a graded relationship to the risk of liver disease that appears to be mediated substantially by behaviors that increase the risk of viral and alcohol-induced liver disease. Understanding the effect of ACEs on the risk of liver disease and development of these behaviors provides insight into causal pathways, which may prove useful in the prevention of liver disease.

From the Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga (Drs Dong, Giles, and Anda and Ms Dube); and the Department of Preventive Medicine, Southern California Permanente Medical Group (Kaiser Permanente), San Diego (Dr Felitti). The authors have no relevant financial interest in this article.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

RELATED LETTERS

Adverse Childhood Experiences, Obesity, and Liver Disease
Keith H. Bachman
Arch Intern Med. 2004;164(4):460.
EXTRACT | FULL TEXT  

Adverse Childhood Experiences, Obesity, and Liver Disease—Reply
Maxia Dong, Shanta R. Dube, Vincent J. Felitti, Wayne H. Giles, and Robert F. Anda
Arch Intern Med. 2004;164(4):460-461.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

"Proportion Explained": A Causal Interpretation for Standard Measures of Indirect Effect?
Hafeman
Am J Epidemiol 2009;0:kwp283v1-kwp283.
ABSTRACT | FULL TEXT  

Health Risk Behaviors and Mental Health Problems as Mediators of the Relationship Between Childhood Abuse and Adult Health
Chartier et al.
AJPH 2009;99:847-854.
ABSTRACT | FULL TEXT  

Childhood Sexual Abuse is Associated With Physical Illness Burden and Functioning in Psychiatric Patients 50 Years of Age and Older
Talbot et al.
Psychosom. Med. 2009;71:417-422.
ABSTRACT | FULL TEXT  

Cumulative Childhood Stress and Autoimmune Diseases in Adults
Dube et al.
Psychosom. Med. 2009;71:243-250.
ABSTRACT | FULL TEXT  

Childhood and Current Determinants of Heavy Drinking in Early Adulthood
Kestila et al.
Alcohol Alcohol 2008;43:460-469.
ABSTRACT | FULL TEXT  

Effects of Enhanced Foster Care on the Long-term Physical and Mental Health of Foster Care Alumni
Kessler et al.
Arch Gen Psychiatry 2008;65:625-633.
ABSTRACT | FULL TEXT  

Obesity and Type 2 Diabetes Risk in Midadult Life: The Role of Childhood Adversity
Thomas et al.
Pediatrics 2008;121:e1240-e1249.
ABSTRACT | FULL TEXT  

The Relationship Between Number of Types of Childhood Trauma, Number of Psychophysiological Disorders, and Length of Medical Disability
Sansone et al.
Traumatology 2006;12:143-147.
ABSTRACT  

Childhood Residential Mobility and Multiple Health Risks During Adolescence and Adulthood: The Hidden Role of Adverse Childhood Experiences
Dong et al.
Arch Pediatr Adolesc Med 2005;159:1104-1110.
ABSTRACT | FULL TEXT  

Insights Into Causal Pathways for Ischemic Heart Disease: Adverse Childhood Experiences Study
Dong et al.
Circulation 2004;110:1761-1766.
ABSTRACT | FULL TEXT  

Adverse Childhood Experiences, Obesity, and Liver Disease
Bachman
Arch Intern Med 2004;164:460-460.
FULL TEXT  

Adverse Childhood Experiences, Obesity, and Liver Disease--Reply
Dong et al.
Arch Intern Med 2004;164:460-461.
FULL TEXT