童年逆境与美国成年人发病和死亡的关联：系统综述。
Association of Childhood Adversity With Morbidity and Mortality in US Adults: A Systematic Review.
机构信息
National Health and Medical Research Council Centre of Research Excellence in PREMISE, The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, New South Wales, Australia.
Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, New York.
出版信息
JAMA Pediatr. 2021 Dec 1;175(12):1269-1278. doi: 10.1001/jamapediatrics.2021.2320.
IMPORTANCE
Childhood adversity (CA) is a powerful determinant of long-term physical and mental health that is associated with elevated risk for chronic disease and psychopathology. However, the degree to which CA contributes to mortality as a preventable driver of ill-health and death is unknown.
OBJECTIVE
To estimate the contribution of CA to health behaviors, including smoking and sedentary behavior, as well as the annual mortality attributable to CA in the US through influences on leading causes of death (eg, cardiovascular disease).
EVIDENCE REVIEW
For this systematic review, the PsycINFO and MEDLINE databases were searched on November 15, 2019. The databases were searched for publications from inception (1806 for PsycINFO, 1946 for MEDLINE) to November 15, 2019. Meta-analyses of the associations between CA and morbidity outcomes were included. The population attributable fraction (PAF) was calculated from these associations along with the estimated US prevalence of CA. The PAF was then applied to the number of annual deaths associated with each cause of death to estimate the number of deaths that are attributable to CA. Additionally, the PAF was applied to the incidence of health behaviors to derive the number of cases attributable to CA. Exposure to 1 or more experiences of adversity before the age of 18 years was analyzed, including abuse, neglect, family violence, and economic adversity.
FINDINGS
A total of 19 meta-analyses with 20 654 832 participants were reviewed. Childhood adversity accounted for approximately 439 072 deaths annually in the US, or 15% of the total US mortality in 2019 (2 854 838 deaths), through associations with leading causes of death (including heart disease, cancer, and suicide). In addition, CA was associated with millions of cases of unhealthy behaviors and disease markers, including more than 22 million cases of sexually transmitted infections, 21 million cases of illicit drug use, 19 million cases of elevated inflammation, and more than 10 million cases each of smoking and physical inactivity. The greatest proportion of outcomes attributable to CA were for suicide attempts and sexually transmitted infections, for which adversity accounted for up to 38% and 33%, respectively.
CONCLUSIONS AND RELEVANCE
The results of this systematic review suggest that CA is a leading contributor to morbidity and mortality in the US and may be considered a preventable determinant of mortality. The prevention of CA and the intervention on pathways that link these experiences to elevated disease risk should be considered a critical public health priority.
重要性
童年逆境（CA）是长期身心健康的有力决定因素，与慢性病和精神病理学风险增加有关。然而，CA 作为导致健康不良和死亡的可预防驱动因素，对死亡率的贡献程度尚不清楚。
目的
通过对主要死因（如心血管疾病）的影响，估计 CA 对美国健康行为（包括吸烟和久坐行为）的贡献，以及 CA 每年归因于美国的死亡率。
证据回顾
对于这项系统评价，于 2019 年 11 月 15 日在 PsycINFO 和 MEDLINE 数据库中进行了搜索。从 1806 年（PsycINFO）和 1946 年（MEDLINE）开始对数据库进行搜索，一直到 2019 年 11 月 15 日。包括 CA 与发病率结果之间的关联的荟萃分析。根据这些关联以及估计的美国 CA 流行率，计算人群归因分数（PAF）。然后，将 PAF 应用于与每种死因相关的年死亡人数，以估计归因于 CA 的死亡人数。此外，将 PAF 应用于健康行为的发生率，以得出归因于 CA 的病例数。分析了 18 岁之前经历的 1 次或多次逆境的暴露情况，包括虐待、忽视、家庭暴力和经济逆境。
发现
共审查了 19 项荟萃分析，涉及 20654832 名参与者。童年逆境在美国每年导致约 439072 人死亡，占 2019 年美国总死亡人数（2854838 人）的 15%，这与主要死因（包括心脏病、癌症和自杀）有关。此外，CA 与数百万人的不健康行为和疾病标志物有关，包括 2200 多万例性传播感染、2100 万例非法药物使用、1900 万例炎症升高，以及超过 1000 万例吸烟和身体活动不足的病例。归因于 CA 的结果比例最大的是自杀未遂和性传播感染，其中逆境分别占 38%和 33%。
结论和相关性
本系统评价的结果表明，CA 是美国发病率和死亡率的主要原因之一，可能被视为死亡率的可预防决定因素。预防 CA 以及干预将这些经历与疾病风险升高联系起来的途径，应被视为一项关键的公共卫生优先事项。
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