Are adverse childhood events a risk factor for diabetes?

The experience of any adverse childhood events (ACEs) does not appear to carry an increased hazard of diabetes, although individuals who faced parental separation, death, or divorce of a parent as a child are more likely to have diabetes, as reported in a Singapore study.

“In addition, we observed a significant interaction between age and ACEs in relation to the odds of diabetes… [such that] ACEs are an important risk factor for diabetes among those belonging to the younger age groups,” the investigators said.

They acknowledged that they were unable to explain the interaction but pointed out that diabetes occurred much sooner among individuals in the age group of 18–49 years as compared with those older than 50 years. “[This] raises the possibility that ACEs may be linked to an earlier onset of diabetes and, thus, are more strongly associated with diabetes in those belonging to the younger age group.”

Several factors explain the role of ACEs in the development of diabetes. ACEs are detrimental to neurodevelopment, exerting a negative impact on the hypothalamic–pituitary–adrenal axis. Also, the events can cause an elevated level of triglycerides, free fatty acids, and glucose in the blood, which can lead to the elevation of inflammatory markers. [Stress 2015;18:446-450; J Endocrinol 2016;230:R77-94; Brain Behav Immun Health 2020;1:100006]

“All of [the above] have been postulated to be involved in the development of chronic illnesses including diabetes,” according to the investigators.

In the study, the investigators used data from the Singapore Mental Health Study, which included 6,106 individuals (50.5 percent female). Most of the participants were aged between 18 and 49 years (60.1 percent), of Chinese ethnicity (75.7 percent), married (59.8 percent), and employed (72.0 percent).

Diabetes had a prevalence rate of 9.7 percent. This figure slightly dropped to 9.5 percent after excluding participants who developed diabetes before age 18 years. The mean age of onset was 48.5 years. [BMJ Open 2021;11:e045167]

Older age, Indian ethnicity, as well as being overweight and obese were associated with a higher likelihood of diabetes, whereas female sex was associated with lower odds. These findings were similar to that reported by the World Health Organization.

A total of 4,441 participants completed the ACE questionnaire. The resulting data showed that among the ACEs covered, only parental separation, divorce, or death of a parent was significantly associated with greater odds of diabetes (adjusted odds ratio [aOR], 1.5, 95 percent confidence interval [CI], 1.01–2.2).

In the younger age group (<50 years), the odds of diabetes were twofold greater among those who had experienced parental separation, divorce, or death of a parent in their childhood (aOR, 2.2, 95 percent CI, 1.1–4.4) and those who went through three or more ACEs (aOR, 2.3, 95 percent CI, 1.1–5.4).

In the older age group, factors associated with a lower likelihood of diabetes included having lived with household members who were mentally ill or suicidal (aOR, 0.2, 95 percent CI, 0.1–0.6) and experience of emotional abuse (aOR, 0.2, 95 percent CI, 0.1–0.5) as a child.

ACE worsens quality of life

Overall, among participants with diabetes, a history of ACEs appeared to aggravate outcomes in terms of comorbidity with major depressive disorder and poorer health-related quality of life (HRQoL).

Stress and inflammatory mechanisms underlie the association between diabetes and depression, according to the researchers. Also, ACEs have been indirectly implicated in the risk of diabetes in adulthood via depressive symptoms. [Prev Med 2019;123:163-170; Diabetes Care 2018;41:2120-2126]

“[I]t therefore follows that those with diabetes and ACEs would have greater cumulative stress that could lead to a higher prevalence of depression in this group… [So], ACEs alone or in combination with depression could have led to a lower HRQoL among those with diabetes,” they pointed out.

Taken together, the findings point to the need to address ACEs across societies to improve health outcomes for the population. The investigators highlighted a need for a multiagency effort across both health and social care sectors to screen, prevent, and provide early care for those who have experienced ACEs.

“However, we must be cognizant that advancing age and body mass index are other important factors associated with diabetes. Thus, efforts to promote regular exercise and healthy lifestyles both in the population and among those with diabetes must continue, along with better identification of and communication about ACEs within the healthcare setting,” they added.