Physical and sexual abuse in childhood and adolescence appear to increase the risk of type 2 diabetes in adult women in a dose-response fashion, based on the results of an epidemiologic study involving almost 70,000 women.

Moderate and severe physical abuse in childhood and adolescence were associated with 26%-54% higher risks of diabetes in women. Those who had experienced forced sex once had a 34% higher risk of diabetes than were women who were not sexually abused as girls and a 69% higher risk when sexual abuse occurred more frequently. Even after accounting for adult body mass index, there remained a 10%-30% increased risk of diabetes among women who had experienced moderate physical abuse or the most severe forms of physical or sexual abuse (Am. J. Prev. Med. [doi:10.1016/j.amepre.2010.09.007]).

“The PAR [population attributable risk] percent derived from this model indicates that child/adolescent abuse accounted for 14% (7%-21%) of type 2 diabetes in this cohort. Applying the hazard ratio from this study to the 43% prevalence of any child or adolescent abuse reported by women in the National Violence Against Women Survey, an estimated 9% of diabetes in U.S. women may be attributed to early abuse,” wrote Janet W. Rich-Edwards, Sc.D., and her colleagues.

An association consistently has been reported between child abuse and adult obesity. Studies indicate “that early trauma may cause lasting dysregulated responsivity, which may link child abuse with diabetes through physiologic pathways independent of adiposity,” wrote Dr. Rich-Edwards, director of developmental epidemiology at the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, Boston, and her colleagues. However, the association between childhood abuse and adult diabetes has not been studied before in a large population.

The new findings highlight the importance of recognizing abuse in children and adolescents and asking adults about a history of abuse, according to Dr. Lawrence S. Phillips, a professor of endocrinology at Emory University, Atlanta.

Physicians need to be aware that “there are not only emotional and behavioral consequences of abuse in childhood and adolescence; there are physical consequences as well,” he said in an interview. “We need to be much more sensitive to issues of abuse and in the history, because they demonstrably now have mental and physical downstream impacts.”

For this study, the researchers used data from the Nurses Health Study II (NHSII), a cohort of 116,430 registered nurses, who were aged 25-42 years when the cohort was established in 1989. The cohort has been followed by biennial mailed questionnaires, which inquire about risk factors and disease incidence.

In 2001, a violence questionnaire was added to this large longitudinal cohort study of women. Participants returned 68,376 violence questionnaires; 67,853 were included in this analysis.

A total of 2,074 cases of type 2 diabetes were accrued from 1989 to 2005, and 759 incident cases occurred after the violence questionnaire was administered in 2001. All of the cases (2,833) were included in the analysis to maximize power. Data were analyzed in 2009, after diagnoses of diabetes reported on the 2005 questionnaire were reviewed and coded.

The Violence Questionnaire covers three periods: childhood (up to age 11 years), adolescence (11-17 years), and adulthood. Childhood and adolescent physical abuse was assessed through an adaptation of the Revised Conflict Tactics Scale. Physical abuse during childhood was categorized into four groups: no physical abuse (none); being “pushed, grabbed, or shoved” at any frequency or being “kicked, bitten, or punched” once or “hit with something” once (mild); being “hit with something” more than once or “physically attacked” once (moderate); being “kicked, bitten, or punched” or “physically attacked” more than once or ever “choked or burned” (severe). Spanking was not included.

Child and adolescent sexual abuse was measured by questions about unwanted sexual touching and forced sexual activity. Exposure was categorized into four groups: no sexual abuse; unwanted sexual touching only; forced sexual activity once; and forced sexual activity more than once. Adult experiences of abuse were measured on the violence questionnaire with questions adapted from the McFarlane Abuse Assessment Screen.

In this cohort, 65% of participants reported any degree of physical or sexual abuse in childhood or adolescence, which was associated with a 24% increased risk of type 2 diabetes in adulthood, even after adjustment for age, race/ethnicity, body type at 5 years, and maternal/paternal education and history of diabetes.

A dose-response association was found between physical abuse and risk of diabetes. However, this was somewhat attenuated by adjustment for race, maternal and paternal education, maternal and paternal diabetes, and somatotype at age 5.

Physical and sexual abuse interacted on an additive scale but not on a multiplicative scale, indicating that the absolute risk of diabetes was greater among women who had experienced both forms of abuse than would be expected from the risk of sexual or physical abuse alone, according to Dr. Rich-Edwards and her coauthors.

At age 5 years, little difference was found between the somatotypes of girls who did and did not report later abuse. By the age of 18 years, however, the BMI trajectories of abused girls had begun to diverge. By ages 25-42 years, a marked trend was found of increasing BMI with more severe abuse history.

Adjustment for adult smoking, alcohol use, and BMI weakened, but did not eliminate the dose-response associations of child and teen abuse with risk of adult diabetes. The attenuation was attributable almost entirely to adjustment for adult BMI, which accounted for 60% and 64% of the associations of physical and sexual abuse respectively with diabetes.

Despite adjustment, moderate physical abuse, severe physical abuse, and repeated forced sex remained independently associated with significantly increased risks of diabetes of 12%, 21%, and 28%, respectively.

Moderate and severe physical abuse were associated with 26%-54% higher risks of diabetes in maturity. Unwanted sexual touching was associated with 16% higher risk of diabetes, and forced sexual activity before adulthood carried a 34% greater risk when it occurred once and a 69% greater risk when it occurred more frequently. Child and teen abuse predicted later diabetes even among women who reported no adult physical or sexual abuse.

“The high prevalence of child abuse suggests that it is an important, if overlooked, contributor to type 2 diabetes ... A more precise description of the physiologic and psychological mechanisms through which abuse leads to overweight and obesity would help to focus prevention efforts. Weight-control interventions designed specifically for survivors of abuse may help to reduce the risk of diabetes,” the investigators concluded.

Dr. Phillips agreed. “If an individual [with a history of abuse] is heavy or is gaining weight or is physically inactive, we need to try to intervene – recognizing that those kinds of changes in these individuals will predispose them to the development of diabetes more than perhaps the general population.”

The authors reported no financial disclosures.

Copyright (c) 2010 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

一项涉及近70,000例女性的流行病学研究表明，儿童和青少年时期遭受身体虐待和性虐待可能会使成年女性2型糖尿病的发病风险增加。

研究者采用的是护士健康研究II(NHSII)的数据，该队列由116,430名注册护士组成，资料创建于1989年，当时这些护士的年龄介于25~42岁。每两年通过邮寄问卷进行随访，对危险因素和疾病的发生情况进行了调查。2001年，在这项大规模女性纵向队列研究中新增了一份涵盖儿童期(0~11岁)、青少年期(11~17岁)和成年期的暴力问卷。采用冲突策略量表对儿童期和青少年期遭受的身体虐待进行评价。儿童期身体虐待分为4组：没有遭受过身体虐待(无)；曾被“推、抓或撞”，不论次数或曾被“踢、咬或重击”一次或曾被“物体打击”一次(轻度)；曾被“物体打击”不止一次或曾遭遇“身体袭击”一次(中度)；曾被“踢、咬或重击” 或曾遭遇“身体袭击”不止一次或曾经“窒息或烧伤”(重度)。打屁股未被纳入问卷。通过提问将儿童期和青少年期性虐待也分为4组：无性虐待；仅非自愿性接触；一次强迫性行为；不止一次强迫性行为。