title: Adverse childhood experiences and self-reported liver disease: new insights into the causal pathway.
abstract: 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.
authors.affiliation: Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA. mfd7@cdc.gov
authors.forename: Maxia
authors.initials: M
authors.lastname: Dong
authors.forename: Shanta R
authors.initials: SR
authors.lastname: Dube
authors.forename: Vincent J
authors.initials: VJ
authors.lastname: Felitti
authors.forename: Wayne H
authors.initials: WH
authors.lastname: Giles
authors.forename: Robert F
authors.initials: RF
authors.lastname: Anda
mesh_terms: D000428:Alcohol Drinking / Q000009:adverse effects / Q000453:epidemiology; D015984:Causality; D002648:Child; D002649:Child Abuse; D005191:Family Characteristics; D005260:Female; D006801:Humans; D008016:Life Change Events; D008107:Liver Diseases / Q000453:epidemiology*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010287:Parent-Child Relations; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D012309:Risk-Taking; D012725:Sexual Behavior; D014481:United States