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. Author manuscript; available in PMC: 2026 Jan 1.
Published in final edited form as: Prev Med. 2022 Jul 3;162:107124. doi: 10.1016/j.ypmed.2022.107124

Adverse childhood experiences and disordered eating among middle-aged adults: Findings from the coronary artery risk development in young adults study

Cynthia Y Yoon a,b,*, Susan M Mason a, Katie Loth c, David R Jacobs Jr a
PMCID: PMC12755113  NIHMSID: NIHMS2119455  PMID: 35787840

Abstract

Adverse childhood experiences (ACEs) include childhood abuse, neglect, and household substance abuse. Childhood abuse is a risk factor for disordered eating (DEB). Less well established are associations of childhood neglect and household substance abuse with DEB, and little research has examined ACE associations with DEB in middle adulthood. The objective of this study was to examine associations between ACEs and DEBs among middle-aged adults and examine sex differences. ACEs prior to age 18 were retrospectively assessed in the Coronary Artery Risk Development in Young Adults study in 2000–2001 (N = 3340, ages 32 to 46). DEB outcomes (i.e., concerns about weight and shape, anxiety about eating or food, unhealthy weight control behaviors, chronic dieting, overeating, and binge eating) were assessed in 1995–1996 (ages 27 to 41). Modified Poisson regressions estimated risk ratios (RRs) for associations of a history of any ACE, each ACE, and cumulative ACEs with DEB outcomes. Among women, emotional abuse, physical neglect, and emotional neglect were each modestly associated with most DEBs (RRs = 1.21–1.35, 1.21–1.45, and 1.23–1.41 across DEBs, respectively) after adjustment for sociodemographic variables, BMI, and depressive symptoms. A cumulative ACE score was associated with all DEBs in a stepwise manner (p for trend ≤0.05) except concerns about weight and shape and overeating. Among men, emotional abuse was most consistently related to the majority of DEBs (RRs = 1.23–1.92); household substance abuse was modestly associated with overeating (RR = 1.26, 95% CI = 1.04–1.53). ACEs were cumulatively associated with unhealthy weight control behaviors, overeating, and binge eating (p for trend <0.01).

Keywords: Adverse childhood experiences (ACEs), Abuse, Neglect, Household substance abuse, Disordered eating, Middle-aged adults, Cohort, Observational study

1. Introduction

Adverse childhood experiences (ACEs) include a variety of potentially developmentally disruptive or traumatic life events that occur in childhood (0–17 years), including but not limited to childhood abuse, neglect, and household substance abuse (Felitti et al., 1998; Dube et al., 2003). ACEs are a public health concern due to their association with a breadth of health outcomes in the biological, psychological, and social domains (Felitti et al., 2019; Gilbert et al., 2015; Vachon et al., 2015; Hawkins et al., 2021; Hughes et al., 2017a; Wade et al., 2016a). In particular, childhood abuse has been consistently found to be a risk factor for physical and mental health (Hawkins et al., 2021; Hughes et al., 2017a; Wade et al., 2016b). More recent studies report that childhood abuse is additionally associated with disordered eating behaviors (Domine et al., 2009´ ; Sachs-Ericsson et al., 2012; Fischer et al., 2010; Preti et al., 2006; Burns et al., 2012; Isohookana et al., 2016; Kent et al., 1999; Neumark-Sztainer et al., 2000; Emery et al., 2021). Trauma theory (Herman, 1992) and stress and coping theory (Lazarus and Folkman, 1984; Lazarus, 1993) suggest that ACEs, in particular childhood abuse, may operate as a traumatic stressor that may lead survivors to engage in disordered eating (Burns et al., 2012; Aaseth et al., 2019; Vilija and Romualdas, 2014; Exner-Cortens et al., 1994; Folkman, 2013; Moulton et al., 2015) as a coping mechanism to dissociate themselves from the emotional distress associated with abuse (Macfie et al., 2001; Gershuny and Thayer, 1999; Vanderlineden et al., 2007; Demitrack et al., 1990). A growing body of literature has considered other ACEs, such as childhood neglect, a risk factor for disordered eating behaviors, but the findings have been inconsistent (Guillaume et al., 2016; Hazzard et al., 2019; Gerke et al., 2006; Fuemmeler et al., 2009). Fewer studies have considered household substance abuse, another component of ACEs, as a risk factor for disordered eating behaviors (Felitti et al., 1998; Felitti et al., 2019).

Thus far, studies examining the association of ACEs with DEBs have focused on a narrow scope of disordered eating behaviors, such as binge eating and unhealthy weight control behaviors (Burns et al., 2012; Aaseth et al., 2019; Vilija and Romualdas, 2014; Exner-Cortens et al., 1994; Folkman, 2013; Moulton et al., 2015), which has left a gap in understanding of other disordered eating behaviors and attitudes including excessive concerns about weight and shape, anxiety about eating or food, and chronic dieting. Comprehensively examining associations of ACEs with a breadth of disordered eating behaviors may assist in clarifying whether ACEs are nonspecific risk factors for a broad range of disordered eating behaviors (i.e., similar strength of associations between ACEs and an array of disordered eating) or whether ACEs are specific risk factors for a particular type of disordered eating behavior. If ACEs are specific risk factors for a particular type of disordered eating behavior, it may further advance our understanding of which ACEs have the greatest independent effects on disordered eating behaviors. Since the three domains of ACEs tend to co-occur (Felitti et al., 1998; Felitti et al., 2019; Hughes et al., 2017b), there may also be added information using a cumulative ACE score (total number of ACEs experienced) (Felitti et al., 1998; Hasselle et al., 2017), but little research has examined the association between cumulative ACEs and disordered eating behaviors (Guillaume et al., 2016). Consequently, whether a graded relationship exists between cumulative ACEs and disordered eating behaviors remains unclear.

Another important gap in the literature is the limited number of studies carried out exploring associations of ACEs with disordered eating behaviors among men (Neumark-Sztainer et al., 2000; Emery et al., 2021; Yoon et al., 2022). However, given that men and women may experience different types of ACEs, and that women’s tendency toward internalizing (Wong and Chang, 2016). versus men’s externalizing behaviors as a coping mechanism (Polivy and Herman, 1993; Haines et al., 2006; Osa et al., 2021), we hypothesize these differences in disordered eating. The wealth of studies conducted in the broader context of adverse experiences among women (Burns et al., 2012; Kent et al., 1999; Guillaume et al., 2016; Gerke et al., 2006; Wong and Chang, 2016; Hund and Espelage, 2006) further suggest that women who experience uncontrollable, unexpected, and unpredictable adverse events, including childhood abuse or intimate partner violence, may engage in controllable disordered eating behaviors such as chronic dieting and restrictive types of unhealthy weight control behaviors to exercise the strength of their self-control and willpower (Wong and Chang, 2016). In contrast, evidence suggests that men with adverse experiences, such as abuse or bullying, may attempt to dissociate from the negative emotions related to adverse experiences or to comfort themselves by overeating and binge eating (Polivy and Herman, 1993; Haines et al., 2006; Osa et al., 2021). However, less is known about sex-based differences in the association of childhood neglect and household substance abuse with disordered eating behaviors.

Finally, to date, studies have shown that disordered eating behaviors (e.g., binge eating, chronic dieting) remain stable from adolescence to young adulthood (Goldschmidt et al., 2014; Neumark-Sztainer et al., 2011), suggesting that ACEs may continue to be associated with DEBs into adulthood. However, the vast majority of the cross-sectional and cohort studies on this topic have focused on either adolescents or young adults (Preti et al., 2006; Burns et al., 2012; Isohookana et al., 2016; Neumark-Sztainer et al., 2000; Emery et al., 2021; Guillaume et al., 2016; Hazzard et al., 2019; Gerke et al., 2006; Fuemmeler et al., 2009; Hasselle et al., 2017; Yoon et al., 2022; Mitchell and Mazzeo, 2005; Hazzard et al., 2021a) and have not followed these participants into adulthood, which has resulted in less knowledge of the association between ACE and DEB in middle-aged adults Examining the associations of ACEs with disordered eating behaviors among middle-aged adults will provide a clearer understanding of whether the effects of ACEs persist into adulthood and informs whether addressing ACEs may be important in providing clinical care for middle-aged adults with disordered eating.

To address these gaps in the literature, we aim to assess the association of a variety of ACEs (i.e., childhood abuse, neglect, and household substance abuse) with a broad range of disordered eating behaviors and attitudes (DEB; i.e., concerns about weight and shape, anxiety about eating or food, unhealthy weight control behaviors, chronic dieting, overeating, and binge eating) in middle-aged adults. We specifically examine the associations of: (1) any history of ACEs with each DEB; (2) each ACE with each DEB; (3) cumulative ACEs and each DEB; and (4) sex differences in these associations. Based on findings in prior studies, we hypothesized that a history of any ACE, and of specific ACEs, will be associated with one or more DEB, in particular with unhealthy weight control behaviors or dieting (Miskinyte et al., 2006). Based on the aforementioned cross-sectional and cohort studies of adolescents and young adults (Preti et al., 2006; Burns et al., 2012; Isohookana et al., 2016; Neumark-Sztainer et al., 2000; Emery et al., 2021; Guillaume et al., 2016; Hazzard et al., 2019; Gerke et al., 2006; Fuemmeler et al., 2009; Hasselle et al., 2017; Yoon et al., 2022; Mitchell and Mazzeo, 2005; Hazzard et al., 2021a) and studies reporting that disordered eating behaviors persist over time (Goldschmidt et al., 2014; Neumark-Sztainer et al., 2011), we hypothesized that each ACE would be related to an array of disordered eating behaviors among middle-aged adults, in accordance with findings of adolescents and young adults. However, we further hypothesized that the findings between ACEs and DEBs would depend on sex, type of ACEs, and DEBs. Last, based on studies suggesting a graded relationship between cumulative ACE and other health outcomes (Felitti et al., 2019; Hughes et al., 2017b; Springer et al., 2007; Afifi TO et al., 2017), we hypothesized that a graded relationship exists between cumulative ACEs and DEB.

2. Method

2.1. Subjects

The study sample was drawn from a community-based longitudinal study, the Coronary Artery Risk Development in Young Adults (CARDIA) study (Friedman et al., 1988). At baseline (1985–1986), 5115 generally healthy adults aged 18 to 30 years old were recruited from four study centers: Birmingham, AL; Chicago, IL; Minneapolis, MN; and Oakland, CA. Participants were recruited by telephone, except in some areas in Minnesota where participants were recruited door-to-door. Eligible participants were given a letter explaining the CARDIA study. The questionnaires used in the present report were presented to the participant as part of the general flow of a clinic examination that lasted for several hours. Details of the CARDIA study design, recruitment of examined subjects can be found elsewhere (Friedman et al., 1988). To date, the CARDIA study participants have been followed up eight times over 30 years. Among the original 5115 participants of the CARDIA study, 3949 participants participated in Year 10 when eating behaviors were assessed. Participants with missing data on DE (n = 58), those who did not participate at Year 15 when ACEs were assessed (n = 536), and those missing data on ACEs (n = 15) were excluded, leaving an analytical sample of 3340 (Appendix A). The Institutional Review Board approved the study at all four CARDIA study centers, and written informed consent was obtained from all study participants.

3. Measurements

3.1. Adverse childhood experiences (ACEs)

Experiences of physical abuse, emotional abuse, physical neglect, emotional neglect, and household substance abuse prior to age 18 were retrospectively assessed in CARDIA Year 15 (2000–2001, age 32–46) using the Risky Family Questionnaire (Demitrack et al., 1990) adapted from the Adverse Childhood Experiences questionnaire (Felitti et al., 1998; Dube et al., 2003). Participants rated the frequencies of all ACEs on a Likert scale (Cronbach’s α =0.76). As recommended by earlier studies (Felitti et al., 1998; Dube et al., 2003) and the Childhood Trauma Questionnaire scoring manual (Bernstein and Fink, 1998), each ACE was dichotomized using varied cutoff points to maximize each adverse childhood experiences’ sensitivity and specificity (Appendix B).

ACEs were treated in three ways: any (≥1) type of adverse childhood experience versus no history of ACEs, a history of each ACE versus no history of that ACE, and cumulative ACEs (0, 1, 2, and 3 or more ACEs) calculated by summing the total number of ACEs.

3.2. Disordered eating behaviors and attitudes (DEB)

DEB was assessed from the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R) (Yanovski, 1993) in CARDIA Year 10 (participants age 27–41 in 1995–96), which assessed the following domains of disordered eating: (1) concerns about weight and shape over the past six months (main or most important concerns); (2) anxiety about eating or food over the past six months (“yes” to ≥3 of 4 questions); (3) unhealthy weight control behaviors over the past three months (yes to ≥1 compensatory behavior questions); (4) chronic dieting since becoming an adult (18 years old or more) (≥ half of the time); (5) overeating over the past six months (yes/no); and (6) binge eating over the past six months (yes/no). Each DEB was dichotomized by following the cutoff points used to clinically diagnose eating disorders (Hughes et al., 2017b), although we slightly relaxed these cut-points to capture subclinical disordered eating (Appendix B). The timeframe of the past three months for unhealthy weight control behaviors and the past six months for overeating mirrors the timeframe used in the Diagnostic and Statistical Manual of Mental Disorders-4 (DSM-4) to diagnose eating disorders (American Psychiatric Association, 1994). Although the DSM-4 did not specify a timeframe for all other disordered eating assessed in the present study, in the present study, the timeframe for such behaviors refers to the past six months (Appendix B). [QEWP-R Internal consistency = 0.75–0.79; moderate concordance between QEWP and Structured Clinical Interview and Eating Disorder Examination (kappa = 0.57)] (Yanovski et al., 1992; Spitzer et al., 1992).

3.3. Covariates

Covariates included sociodemographic variables, including age, race, maximum years of educational attainment, study center, body mass index (BMI), and depressive symptoms collected with standard structured questionnaires in CARDIA Year 15 when adverse childhood experiences were assessed.

3.4. Statistical analysis

Participants’ demographic characteristics are presented as the mean with standard deviation (SD) or percentage frequency. t-tests and chi-square tests were conducted to examine differences between women and men.

To examine associations between (1) a history of any ACEs and DEB, (2) each type of ACE and DEB, and (3) cumulative ACEs and DEB, modified Poisson regressions with a robust error variance (Zou, 2004) were used to generate conservative relative risk (RR) and 95% confidence intervals (CIs). The RR compares the risk of DEBs in those with and without ACEs. An RR of 1.0 indicates no association (i.e., null). The 95% CIs for each estimate show its precision and statistical compatibility with the null hypothesis. All models were adjusted for sociodemographic variables (i.e., age, race, and maximum educational attainment), study center, BMI, and depressive symptoms. To investigate the independent association between each ACE type and DEB, the final models were further adjusted for each ACE. Because ACEs may operate via another type of ACE, adjustment for each ACE may result in overadjustment and remove some of the effect. For this reason, we present models with and without mutual adjustment for each ACE. Preliminary analyses indicated that tests for interaction between adverse experiences and sex on eating behaviors were nonsignificant (p = 0.05 to 0.98). However, due to prior evidence of sex differences in the associations of ACEs with DEB (Isohookana et al., 2016; Neumark-Sztainer et al., 2000; Fuemmeler et al., 2009), we present sex-stratified results. All analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC).

4. Results

4.1. Characteristics of the analytic sample

Among the 3340 generally healthy middle-aged adults in our study (mean age 40.2 ± 3.6 years when ACEs were retrospectively assessed in 2000–2001), 56.2% (n = 1024) and 43.8% (n = 797) of women and men, respectively reported a history of any ACEs. Regarding disordered eating, 58.8% (n = 1129) and 43.8% (n = 791) of women and men reported any disordered eating. Women in the study had significantly higher educational attainment than men. The characteristics of the analytic sample did not differ from the original sample of the CARDIA study (Table 1).

Table 1.

Baseline characteristics of participants in 2000–2001 (N = 3340).

Women
N = 1855 (55.5%)		 Men
N = 1485 (44.5%)		 P value
Age in years (M ± SD) 40.2 ± 3.7 40.2 ± 3.7 0.99
Race (column %) <0.01
 Black 906 (48.8) 631 (42.5)
 White 949 (51.2) 854 (57.5)
Educational attainment in yrs. (SD) 15.7 (2.5) 15.5 (2.7) <0.01
BMI (M ± SD) (kg/m2) 29.1 ± 7.7 28.2 ± 5.5 <0.01
Adverse childhood experiences (ACEs), N (column %)
 Any 1024 (55.2) 797 (53.7) 0.38
 Physical abuse 376 (20.3) 272 (18.3) 0.16
 Emotional abuse 394 (21.2) 233 (15.7) <0.01
 Physical neglect 426 (23.0) 384 25.9) 0.05
 Emotional neglect 302 (16.3) 178 (12.0) <0.01
 Household dysfunction 577 (31.1) 406 (27.3) 0.02
Disordered eating
 N (column %)
 Any 1129 (60.9) 791 (53.3) <0.01
 Concerns about weight and shape 629 (33.9) 342 (23.0) <0.01
 Anxiety about eating or food 408 (22.0) 186 (12.5) <0.01
 Unhealthy weight control behaviors 333 18.0) 197 (13.3) <0.01
 Chronic dieting 453 (24.4) 85 (5.7) <0.01
 Overeating 263 (14.2) 364 (24.5) <0.01
 Binge eating 169 (9.1) 87 (5.9) <0.01
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4.2. Prevalence of adverse childhood experiences

The prevalence of all ACEs, except physical neglect was greater among women than men. Among women, the prevalence of ACEs ranged from 16.3% (childhood emotional neglect) to 31.1% (household substance abuse). Regarding cumulative experiences of ACEs, 44.8% (n = 831), 24.5% (n = 455), 14.3% (n = 265), and 16.4% (n =304) of women experienced none, one, two, and three or more ACEs, respectively (Appendix C).

4.3. Associations between history of any adverse childhood experiences and disordered eating

Among women, a history of ACEs was associated with elevated RRs for anxiety about eating or food (RR = 1.35, 95% CI = 1.13–1.62), chronic dieting (RR = 1.20, 95% CI = 1.01–1.41), and binge eating (RR = 1.49, 95% CI = 1.09–2.04) after adjustment for sociodemographic variables, BMI, and depressive symptoms (Table 2, Appendix D). Associations of a history of any ACE with all other DEBs showed no association.

Table 2.

Association between each adverse childhood experiences and disordered eating among women (N = 1855) and men (N = 1485).

Women (n = 1855) Concerns about weight and shape Anxiety about eating or food Unhealthy weight control Chronic dieting Overeating Binge eating
Any Model 1 0.96 (0.85–1.10) 1.35 (1.13–1.62) 1.10 (0.90–1.34) 1.20 (1.01–1.41) 1.15 (0.91–1.46) 1.49 (1.09–2.04)
Physical abuse (n = 376) Model 1 0.99 (0.85–1.15) 1.17 (0.96–1.43) 1.24 (1.00–1.54) 1.08 (0.90–1.30) 1.14 (0.87–1.49) 1.06 (0.75–1.49)
Model 2 1.02 (0.86–1.21) 1.08 (0.86–1.36) 1.05 (0.82–1.35) 1.00 (0.80–1.24) 1.13 (0.84–1.52) 0.89 (0.59–1.35)
Emotional abuse (n = 394) Model 1 0.96 (0.82–1.12) 1.21 (1.00–1.47) 1.35 (1.09–1.68) 1.15 (0.96–1.38) 1.03 (0.79–1.36) 1.22 (0.87–1.72)
Model 2 0.98 (0.82–1.18) 1.18 (0.93–1.49) 1.29 (1.01–1.67) 1.10 (0.89–1.37) 0.95 (0.69–1.31) 1.12 (0.73–1.71)
Physical neglect (n = 426) Model 1 1.06 (0.91–1.23) 1.27 (1.05–1.53) 1.26 (1.02–1.57) 1.04 (0.86–1.25) 1.21 (0.94–1.57) 1.45 (1.05–2.00)
Model 2 1.12 (0.95–1.32) 1.27 (1.02–1.59) 1.18 (0.94–1.50) 0.95 (0.77–1.18) 1.23 (0.92–1.64) 1.37 (0.93–2.00)
Emotional neglect (n = 302) Model 1 0.94 (0.79–1.12) 1.02 (0.80–1.29) 1.25 (0.98–1.59) 1.23 (1.01–1.50) 0.97 (0.71–1.32) 1.41 (0.99–2.00)
Model 2 0.92 (0.75–1.12) 0.85 (0.65–1.12) 1.07 (0.82–1.41) 1.21 (0.96–1.53) 0.87 (0.60–1.24) 1.24 (0.82–1.87)
Household substance abuse (n = 577) Model 1 0.88 (0.76–1.01) 1.01 (0.84–1.22) 0.95 (0.77–1.17) 1.04 (0.87–1.23) 1.11 (0.88–1.41) 1.03 (0.75–1.41)
Model 2 0.87 (0.75–1.01) 0.94 (0.77–1.14) 0.86 (0.69–1.07) 1.00 (0.84–1.20) 1.08 (0.84–1.38) 0.95 (0.68–1.32)
Men (n = 1485) Concerns about weight and shape Anxiety about eating or food Unhealthy weight control Chronic dieting Overeating Binge eating
Any Model 1 1.01 (0.83–1.23) 0.89 (0.67–1.17) 1.32 (1.01–1.74) 0.89 (0.57–1.38) 1.55 (1.27–1.89) 1.39 (0.89–2.15)
Physical abuse (n = 272) Model 1 0.99 (0.77–1.26) 1.03 (0.73–1.46) 1.53 (1.15–2.06) 0.81 (0.45–1.48) 1.47 (1.20–1.80) 1.50 (0.95–2.37)
Model 2 0.86 (0.66–1.12) 1.06 (0.73–1.54) 1.24 (0.89–1.72) 0.77 (0.42–1.41) 1.42 (1.13–1.80) 1.26 (0.76–2.08)
Emotional abuse (n = 233) Model 1 1.34 (1.07–1.68) 0.97 (0.69–1.37) 1.92 (1.44–2.56) 1.23 (0.77–1.97) 1.18 (0.94–1.47) 1.73 (1.10–2.73)
Model 2 1.42 (1.11–1.82) 0.94 (0.63–1.40) 1.88 (1.34–2.64) 1.16 (0.66–2.05) 1.00 (0.78–1.29) 1.55 (0.88–2.73)
Physical neglect (n = 384) Model 1 1.26 (1.02–1.55) 0.94 (0.69–1.29) 0.99 (0.73–1.33) 0.70 (0.41–1.18) 1.19 (0.97–1.45) 1.16 (0.74–1.81)
Model 2 1.25 (1.01–1.56) 0.92 (0.66–1.28) 0.94 (0.69–1.29) 0.60 (0.34–1.06) 1.14 (0.92–1.41) 1.08 (0.62–1.86)
Emotional neglect (n = 178) Model 1 1.22 (0.93–1.59) 1.10 (0.75–1.60) 0.96 (0.64–1.43) 1.74 (1.05–2.90) 0.94 (0.71–1.25) 1.31 (0.77–2.22)
Model 2 1.10 (0.82–1.47) 1.16 (0.77–1.74) 0.77 (0.50–1.18) 2.02 (1.10–3.71) 0.79 (0.58–1.08) 1.04 (0.66–1.65)
Household substance abuse (n = 406) Model 1 0.83 (0.67–1.04) 0.95 (0.70–1.28) 1.11 (0.84–1.47) 1.01 (0.64–1.60) 1.26 (1.04–1.53) 1.12 (0.72–1.76)
Model 2 0.77 (0.61–0.96) 0.95 (0.70–1.28) 1.01 (0.76–1.35) 0.95 (0.59–1.55) 1.21 (0.99–1.48) 0.99 (0.61–1.60)
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Unhealthy weight control behaviors include use of diet pills, vomiting, use of laxatives, use of diuretics, fasting, and meal replacement.

Model 1 adjusted for sociodemographic variables (age, race, maximum educational attainment, and study center), BMI, and depressive symptoms.

Model 2: Model 1+ mutually adjusted for other ACEs.

Among men, a history of ACEs was associated with 1.32 times the risk of unhealthy weight control behaviors (95% CI =1.01–1.74), 1.55 times the risk of overeating (95% CI = 1.27–1.89), and 1.51 times the risk of binge eating (95% CI = 0.89–2.15), although some associations overlapped with the null value. All other associations were close to the null (Table 2, Appendix D).

4.4. Associations between each type of adverse childhood experience and disordered eating

4.4.1. Physical abuse

Among women, physical abuse was associated with 1.24 (95% CI: 1.00–1.54) times the risk of unhealthy weight control behaviors (Table 2 Appendix D). After further adjustment for ACE, the association was attenuated and was close to the null value (Appendix D).

Among men, physical abuse was associated with 1.53 (95% CI: 1.15–2.06), 1.47 (95% CI: 1.20–1.80), and 1.50 (95% CI: 0.95–2.37) times the risk of unhealthy weight control behaviors, overeating, and binge eating respectively (Table 2, Appendix D). Associations with other DEBs were close to the null. After mutual adjustment for all ACEs, physical abuse retained its association with overeating and showed an elevated, although attenuated, RR for unhealthy weight control behaviors and binge eating (Appendix D).

4.4.2. Emotional abuse

Among women, emotional abuse was associated with 1.35 (95% CI: 1.09–1.68) times the risk of unhealthy weight control behaviors. Emotional abuse also showed elevated RRs for anxiety about eating or food and binge eating, although CIs included the null value. After adjustment for ACEs, emotional abuse still had a suggestive association with unhealthy weight control behaviors.

Among men, emotional abuse was associated with 1.34 (95% CI: 1.07–1.68) times the risk of concerns about weight and shape, 1.92 (95% CI: 1.44–2.56) times the risk of unhealthy weight control behaviors; and 1.73 (95% CI: 1.10–2.73) times the risk of binge eating. The association with anxiety about eating or food itself was close to the null. For all other DEB outcomes, emotional abuse showed elevated RRs, but 95% CIs were wide and included the null. After adjustment for other ACEs, emotional abuse still showed an independent association with concerns about weight and shape and unhealthy weight control behaviors; emotional abuse retained a suggestive association with binge eating.

4.4.3. Physical neglect

Among women, physical neglect was associated with 1.27 (95% CI: 1.05–1.53), 1.26 (95% CI: 1.02–1.57), 1.21 (95% CI: 0.94–1.57), and 1.45 (95% CI: 1.05–2.00) times the risk of anxiety about eating and food, unhealthy weight control behaviors, overeating, and binge eating, respectively. After adjustment for ACEs, physical neglect retained an independent association with anxiety about eating; physical neglect retained a modest association with unhealthy weight control behaviors, overeating, and binge eating.

Among men, physical neglect was associated with 1.19 times the risk of overeating (95% CI: 0.97–1.45) and 1.26 times the risk of concerns about weight and shape (95% CI: 1.02–1.55). All other associations were close to the null. After adjustment for each ACE, physical neglect retained a significant association with concerns about weight and shape, but not with any other DEBs.

4.4.4. Emotional neglect

Among women, emotional neglect was associated with 1.25 times the risk of unhealthy weight control behaviors (95% CI: 0.98–1.59), 1.23 times the risk of chronic dieting (95% CI: 1.01–1.50), and 1.41 times the risk of binge eating (95% CI: 0.99–2.00). After adjustment for ACEs, those who had suffered emotional neglect were found to have an elevated risk of chronic dieting and binge eating.

Among men, emotional neglect was associated with 1.74 (95% CI: 1.05–2.90) times the risk of chronic dieting. Emotional neglect showed elevated RRs for concerns about weight and shape and binge eating, but with CIs including the null value. After adjustment for other ACEs, chronic dieting remained associated with chronic dieting, while all other associations attenuated and were closer to the null value.

4.4.5. Household substance abuse

Among women, regardless of the level of adjustment, there were no meaningful associations found between household substance abuse and DEB outcomes.

Among men, household substance abuse was associated with 1.26 times the risk of overeating. All other associations of household substance abuse with DEB were close to the null value (RR range: 0.83–1.12). After adjustment for other ACEs, a modest association remained with overeating.

4.5. Risk of disordered eating by cumulative experience of adverse childhood experiences

Among women, ACEs were cumulatively associated with anxiety about eating or food, unhealthy weight control behaviors, and binge eating (p for trend ≤0.05) (Fig. 1, Appendix E).

Fig. 1.

Fig. 1.

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Associations between cumulative adverse childhood experiences and disordered eating among women (N = 1855) and men (N = 1485).

Note: Unhealthy weight control behaviors include use of diet pills, vomiting, use of laxatives, use of diuretics, fasting, and meal replacement.

Adjusted for sociodemographic variables (age, race, maximum educational attainment, and study center), BMI, and depressive symptoms.

Among men, ACEs were cumulatively associated with unhealthy weight control behaviors, overeating, and binge eating (p for trend ≤0.05) but not with other DEB outcomes (Fig. 1, Appendix E).

5. Discussion

The aims of this study were to examine the association of ACEs (i.e., abuse, neglect, and household substance abuse) with a broad range of DEBs (i.e., concerns about weight and shape, anxiety about eating or food, unhealthy weight control behaviors, chronic dieting, overeating, and binge eating). Overall, our findings suggest a greater risk of DEB among middle-aged adults with a history of ACEs than among adults without a history of ACEs, although the magnitude depended on sex, ACE type, and DEB. For example, among women, the strongest association was observed between a history of physical neglect and binge eating, whereas among men, the strongest association was between emotional abuse and unhealthy weight control behaviors. Our finding that most of the associations were retained even after accounting for socioeconomic status, BMI, and depressive symptoms suggests that the associations of ACEs and DEB do not result from those with lower socioeconomic status, heavier body weights, or depressive symptoms being both more likely to report ACEs and DEBs.

Our finding that childhood abuse was associated with a broad range of DEB is largely consistent with a substantial body of literature (Sachs-Ericsson et al., 2012; Fischer et al., 2010; Burns et al., 2012; Kent et al., 1999; Neumark-Sztainer et al., 2000; Gerke et al., 2006; Fuemmeler et al., 2009), although a few studies of women (Guillaume et al., 2016) and young adults (Hazzard et al., 2019) have found modest or close to null associations between emotional abuse and DEB. The heightened risk of overeating, binge eating, and weight-related eating behaviors and concerns among middle-aged adults with a history of childhood abuse in this study suggests that childhood abuse may have a long-lasting effect on eating behaviors. Although our findings further support the small but growing literature that reports that associations of abuse and DEBs are stronger among men than women (Emery et al., 2021; Yoon et al., 2022), the difference of the baseline risk factors between men and women should be accounted. For instance, for women, the effect of childhood abuse on DEB may have resulted in a smaller point estimate due to the greater background risk factors (e.g., greater sociocultural pressure to be thin) for disordered eating behaviors. Meanwhile, for men, the greater point estimate may be attributed to the fewer baseline risk factors for disordered eating behaviors compared to women.

The finding that childhood neglect was related to several specific types of DEB in our study further supports the growing body of the literature that documents an association between childhood neglect and a spectrum of DEBs in young adults (Kent et al., 1999; Emery et al., 2021; Fuemmeler et al., 2009).However, other studies of young adults (Guillaume et al., 2016; Hazzard et al., 2019) have reported either suggestive but non-statistically significant or close to null associations of neglect with disordered eating. The discrepancy across prior studies may have occurred due to the small sample size of young women in one study (Guillaume et al., 2016) and the non-stratified results reported in the other study of young adults (Hazzard et al., 2019). However, we note that in our study of middle-aged adults, childhood neglect was associated with various disordered eating behaviors in both women and men. Our findings suggest that some survivors of omission of care in childhood may experience long-lasting effects and engage in disordered eating attitudes to manage neglect-related distress, although future studies should be conducted to replicate our findings, given the mixed findings in the literature.

Another novel contribution of our study is the finding that among men but not among women, household substance abuse was associated with overeating, although the magnitude was similar to or less than the association of physical abuse and overeating. To the best of our knowledge, only one study has considered household substance abuse as a risk factor for eating behaviors, and that study was limited to diagnosed eating disorders (Afifi TO et al., 2017). Thus, our findings extend the literature and increase our knowledge of the potential impact of childhood substance abuse in adulthood. It is possible that survivors of household substance abuse, such as survivors of maltreatment, may engage in overeating as a strategy to regulate or reduce negative emotions (Heilbronn et al., 2006; Moreno-Domínguez et al., 2012) related to household substance abuse. It is also possible that household substance abuse may be a proxy indicating other underlying family vulnerabilities (e.g., propensity toward mental health challenges), which may lead survivors to engage in DEB (Daley, 2013). The finding between household substance abuse and overeating among men calls for future studies to explore other relevant experiences related to household function (e.g., parental divorce) are associated with disordered eating behaviors.

Finally, expanding on other studies examining cumulative associations between ACEs and disordered eating (Guillaume et al., 2016) and other outcomes (Felitti et al., 1998), we find that ACEs are cumulatively associated with a broad range of DEB among middle-aged adults. Thus, our findings illustrate that those who survive from repeated victimization of ACEs might be at greater risk of a broad range of DEBs and that this elevated risk may extend for many years in adulthood.

The strengths of our study include the large sample size and the inclusion of women and men, which increases the generalizability of our findings and enables us to stratify the results by sex. Furthermore, unlike other studies that focused exclusively on a single domain or type of adversity, our study was designed to comprehensively assess a broad range of ACEs, including less-studied ACEs such as neglect and household substance abuse. We also examined whether each ACE was independently associated with DEB by mutual adjustment for other ACEs. Finally, the dataset allowed us to examine the association of ACEs with DEB among individuals approaching mid-adulthood (27–41 years). Therefore, our findings extend the current literature, which has largely focused on the associations of childhood abuse with eating behaviors during adolescence or young adulthood.

Despite the strengths of our study, several limitations should be considered in the interpretation of our findings. First, to assess ACEs, which are typically sensitive topics, we relied on participant self-reports of past adverse experiences. The validity of retrospective self-reports of ACEs have questioned for various reasons, such as adults not being able to recall events from their early lives (Pillemer and White, 1989), participants not being willing to disclose sensitive information to avoid distress or embarrassment (Hardt and Rutter, 2004), and the potential that some participants may falsely recall adverse childhood experiences (Susser and Widom, 2012; Colman et al., 2016). Thus, retrospective recalls of ACEs in our study may have resulted in misclassification, in which case, our findings may have under- or overestimated the results (Reuben et al., 2016). However, it is unclear that other types of measurement of ACES are superior to retrospective self-report. For example, prospectively collecting data on ACEs from children or their parents raises ethical issues and may suffer from even greater reporting bias given that children may not be able or willing to divulge these events, and parents can be reported to child welfare if they disclose harm to their children. Likewise, official reports to child welfare could theoretically be used as an objective measure of ACEs, but there is widespread agreement that official reports captures a small and potentially biased subset of all individuals who experience ACEs (Negriff et al., 2017). Further, studies have shown moderate agreement between retrospective and prospectively collected ACEs (Reuben et al., 2016), which supports the use of retrospective assessments of ACEs in large epidemiological datasets (Emery et al., 2021; Hazzard et al., 2019; Yoon et al., 2022; Hazzard et al., 2021b; Yoon et al., 2021). Second, the study did not capture all ACEs included in the original ACE scale. For example, sexual abuse or living with a family member with mental illness were not assessed. Moreover, the duration (i.e., chronicity), severity, timing, repetition of ACEs during childhood, and other types of adverse experiences such as community-level adversities (e.g., violent crime) were not taken into account. Third, because sexual identities aside from male and female were not queried in this study, our findings may not be generalizable to of those who identify as having a nonbinary gender. Future studies should consider examining how the associations may differ by sexual identity, which may further assist in developing inclusive intervention and preventive care. Fourth, future studies should consider replication of this study with participants comprised of more recent generations, given that ACEs and DEBs were assessed nearly four and three decades ago, respectively, and the prevalence of each may have changed over time. Fifth, we note that several estimates included small numbers of participants, which may have led to imprecision in our estimates accompanied by wide confidence intervals. As in all epidemiological studies, our research is limited by potential residual confounding due to unmeasured or unknown confounders. Finally, adversity experienced prior to age 18 was retrospectively recalled in CARDIA Year 15, and DEBs were assessed in CARDIA Year 10. Although we assume that adverse childhood experiences precede DEBs, we note the possibility of reverse causality. That is, DEB might have occurred in the early years prior to the occurrence of ACEs.

The findings of our study have several implications for policy makers, researchers, and practitioners. First, efforts should be made to prevent childhood abuse, neglect, and household substance abuse. Our finding that childhood neglect and household substance abuse were the two most prevalent types of ACEs in this study, and their association with DEB, stress the urgent need for public health efforts to be established to prevent these types of ACEs. For researchers, the findings further illustrate the need for a more comprehensive assessment of ACEs, including neglect and household substance abuse and the need to examine the long-lasting effect on physical and mental health and wellbeing. Furthermore, there is a need to understand the underlying cause of why certain, but not all, survivors of abuse, neglect, and household substance abuse may engage in DEB and what factors may help survivors build resilience to resist engaging in such behaviors. The greater magnitude of many associations among men, a group that has been largely neglected by researchers of disordered eating, suggests a need for continued studies exploring the association between ACEs and DEB in this population. For practitioners working with survivors of ACEs, a comprehensive screening of ACEs may assist in understanding patients’ risk profiles. The findings among men suggest particularly that clinicians should ensure that they consider the potential for men with ACEs to be at risk for DEBs, despite much of the research emphasizing these associations in women. To prevent survivors of ACEs from engaging in DEB in response to their past adverse experiences, health professionals may assist in adopting healthy coping strategies.

6. Conclusion

Individual and cumulative ACEs are associated with DEB, although the magnitude differs by sex, type of ACE, and DEB and may depend on the social context. The possible long-lasting deleterious effects of each ACE on DEB among middle-aged adults underscore the need to address ACEs in research and in practice. Identifying factors associated with resiliency may assist in preventing survivors of ACEs from engaging in DEB.

Funding

The CARDIA study is supported by contracts HHSN268201800003I, HHSN268201800004I, HHSN268201800005I, HHSN268201800006I, and HHSN268201800007I from the National Heart, Lung, and Blood Institute (NHLBI). Cynthia Yoon’s time was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) [T32DK083250]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NHLBI or NIDDK.

Abbreviations:

ACEs

Adverse childhood experiences

DEB

Disordered eating behaviors and attitudes.

Appendix

Appendix A. Flow chart showing the number of participants included in the analysis.

Appendix A.

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Appendix B.

Verbatim questions and cut off points used to dichotomize adverse childhood experience variables and disordered eating

ACE domain Verbatim question Available response options Cutoff point
Physical abuse How often did a parent or other adult in the household push, grab, shove, or hit you so hard you had marks or were injured? Rarely or never
Sometimes or a little
Occasionally or a moderate amount of the time
Most or all of the time		 0: Rarely/none of the time
1: Some/ little; occasionally/moderate; most/all of the time
Emotional abuse How often did a parent or other adult in the household swear at you, insult you, put you down or act in a way that made you feel threatened? Rarely or never
Sometimes or a little
Occasionally or a moderate amount of the time
Most or all of the time		 0: Rarely/none of the time; some/little
1: Occasionally/moderate; most/all of the time
Physical neglect Did your family know what you were up to? Rarely or never
Sometimes or a little
Occasionally or a moderate amount of the time
Most or all of the time		 0: Occasionally/moderate; most/all of the time
1: Rarely/none of the time; some/little
Emotional neglect How often did a parent or other adult in the household make you feel that you were loved, supported, and cared for? Rarely or never
Sometimes or a little
Occasionally or a moderate amount of the time
Most or all of the time		 0: Occasionally/moderate; most/all of the time
1: Rarely/none of the time; some/little
Household substance abuse Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? Rarely or never
Sometimes or a little
Occasionally or a moderate amount of the time
Most or all of the time		 0: Rarely/none of the time
1: Some/little; occasionally/moderate; most/all of the time
Disordered eating constructs Concerns about weight and shape Verbatim questions from the QEWP-R
During the past six months, how important has your weight or shape been in how you feel about or evaluate yourself compared to other aspects of your life, such as how you do at work, as a parent, or how you get along with other people?		 QEWP-R response options
1: Not very important
2: Played a part
3: Was among the main things
4: Was the most important things		 Points assigned in study
0: Not very important or played a part
1: a main thing or more
Anxiety about eating or food In the past 6 months, did you have any of the following experiences:
Eating much more rapidly than usual?
Eating until you felt uncomfortably full?
Eating large amounts of food when you didn’t feel physically hungry?
Eating alone because you were embarrassed by how much you were eating?
Feeling disgusted with yourself, depressed, or feeling very guilty after overeating?		 Yes or no to each of 5 items 0: Answered ‘yes’ to <3 questions out of 5 questions
1: Answered ‘yes’ to 3 or more questions out of 5 questions
Unhealthy weight control behaviors to avoid weight gain In the past 3 months, did you ever:
Make yourself vomit in order to avoid gaining weight or to lose weight?
Take more than twice the recommended dose of laxatives in order to avoid gaining weight or to lose weight?
Take more than twice the recommended dose of diuretics (water pills) in order to avoid gaining weight or to lose weight?
Take more than twice the recommended dose of a diet pill in order to avoid gaining weight or to lose weight?
Fast (not eat anything at all for at least 24 h) in order to avoid gaining weight or to lose weight?
Use any dietary products, such as SlimFast, fiber bars or protein powders, for meal replacement to avoid gaining weight or to lose weight?		 Yes or no 0: Answered no to all of the compensatory behavior questions

1: Answered yes to 1 or more of the compensatory behavior questions
Chronic dieting to lose weight or prevent weight gain Since you have been an adult (18 years old) how much of the time have you been on a diet, been trying to follow a diet, or in some way been limiting how much you were eating in order to lose weight or keep from regaining weight you had lost? 0: None or hardly any of the time
1: About a quarter of the time
2: About half of the time
3: About three-quarters of the time
4: Nearly all the time		 0: None or hardly any of the time or about a quarter of the time

1: About or more than half of the time
Overeating During the past six months, did you often eat within any two-hour period what most people would regard as an unusually large amount of food?
During the times when you ate this way, did you often feel you couldn’t stop eating or control what or how much you were eating?		 0: No
1: Yes		 0: No
1: Yes to eating large quantities of food without sense of loss of control
0: No
1: Yes
Binge eating During the past six months, did you often eat within any two-hour period what most people would regard as an unusually large amount of food?
During the times when you ate this way, did you often feel you couldn’t stop eating or control what or how much you were eating?		 0: No
1: Yes		 0: No
1: Yes to both questions
0: No
1: Yes
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Appendix C. Prevalence of adverse childhood experiences by sex (N = 1855 women and N = 1485 men).

Appendix C.

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Note: * denotes a statistically significant difference in ACE prevalence between women and men (p < 0.05).

Women N = 1855 (childhood physical abuse n = 376; childhood emotional abuse n = 394; childhood physical neglect n = 426; childhood emotional neglect n = 302; household substance abuse n = 577).

Men N = 1485 (childhood physical abuse n = 272; childhood emotional abuse n = 233; childhood physical neglect n = 384; childhood emotional neglect n = 178; household substance abuse n = 406).

Appendix D. Associations between adverse childhood experiences and disordered eating by types of adverse experiences among women (N = 1855) and men (N = 1485).

Appendix D.

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Note:

Any = any adverse experience; Pabuse = physical abuse; Eabuse = emotional abuse; Pneglect = physical neglect; Eneglect = emotional neglect; Household = household substance abuse.

Unhealthy weight control behaviors include use of diet pills, vomiting, use of laxatives, use of diuretics, fasting, and meal replacement.

Adjusted for sociodemographic variables (age, race, maximum educational attainment, and study center), BMI, and depressive symptoms.

Appendix E.

Association between the cumulative number of adverse childhood experiences and disordered eating among women (N = 1855) and men (N = 1455)

Adverse childhood experiences Concerns about weight and shape Anxiety about eating or food Unhealthy weight control Chronic dieting Overeating Binge eating
Women
0 (n = 687) 1.00 1.00 1.00 1.00 1.00 1.00
1 (n = 405) 0.99 (0.85–1.16) 1.36 (1.10–1.68) 0.82 (0.63–1.08) 1.17 (0.96–1.43) 1.07 (0.80–1.43) 1.38 (0.94–2.02)
2 (n = 203) 0.97 (0.80–1.18) 1.50 (1.18–1.92) 1.38 (1.06–1.79) 1.31 (1.05–1.64) 1.31 (0.95–1.80) 1.71 (1.13–2.59)
≥3 (n = 188) 0.92 (0.76–1.10) 1.22 (0.95–1.57) 1.27 (0.98–1.66) 1.13 (0.90–1.42) 1.15 (0.83–1.59) 1.47 (0.97–2.23)
P trend 0.36 0.02 0.02 0.09 0.21 0.02
Men
0 (n = 829) 1.00 1.00 1.00 1.00 1.00 1.00
1 (n = 454) 0.92 (0.72–1.16) 0.79 (0.56–1.11) 1.17 (0.84–1.63) 0.72 (0.41–1.27) 1.57 (1.26–1.96) 1.09 (0.63–1.87)
2 (n = 265) 1.11 (0.83–1.48) 1.11 (0.75–1.65) 1.56 (1.07–2.28) 1.17 (0.64–2.15) 1.48 (1.12–1.95) 1.82 (1.03–3.22)
≥3 (n = 304) 1.12 (0.84–1.50) 0.89 (0.58–1.36) 1.42 (0.96–2.10) 0.99 (0.54–1.83) 1.56 (1.18–2.06) 1.62 (0.90–2.93)
P trend 0.38 0.82 0.03 0.85 <0.01 0.05
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Unhealthy weight control behaviors include use of diet pills, vomiting, use of laxatives, use of diuretics, fasting, and meal replacement.

Adjusted for sociodemographic variables (age, race, maximum educational attainment, study center, BMI, and depressive symptoms.

Footnotes

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

CRediT authorship contribution statement

Cynthia Y. Yoon: Conceptualization, Methodology, Data curation, Writing – original draft. Susan M. Mason: Conceptualization, Writing – review & editing, Supervision. Katie Loth: Writing – review & editing. David R. Jacobs: Funding acquisition, Project administration, Investigation, Resources, Validation, Writing – review & editing, Supervision.

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