不健康生活方式在童年不良经历与共病关联中的中介效应

冯红曼; 许向辉; 刘明月; 陈新洋; 李小明

doi:10.16462/j.cnki.zhjbkz.2025.08.017

不健康生活方式在童年不良经历与共病关联中的中介效应

doi: 10.16462/j.cnki.zhjbkz.2025.08.017

冯红曼^{1, 4},
许向辉²,
刘明月^{1, 3},
陈新洋^{1, 3},
李小明^{1, 3, ,}

1.
华北理工大学公共卫生学院预防医学系，唐山 063210
2.
华北理工大学医院内科，唐山 063210
3.
河北省煤矿卫生与安全重点实验室，唐山 063210
4.
西安交通大学公共卫生学院流行病与卫生统计学系，西安 710061

基金项目:

国家科技部重点研发项目 2016YFC0900605

科技创新2030-“脑科学与类脑研究”重大项目 2021ZD0200700

河北省高等学校科学技术研究项目 QN2019190

唐山市市级科技计划项目 22130234H

详细信息

通讯作者:
李小明，E-mail: lxmxxh@163.com

中图分类号: R181.3
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出版历程
- 收稿日期: 2024-10-25
- 修回日期: 2025-04-29
- 刊出日期: 2025-08-10

The effect of unhealthy lifestyle on the association between adverse childhood experiences and multimorbidity

FENG Hongman^{1, 4},
XU Xianghui²,
LIU Mingyue^{1, 3},
CHEN Xinyang^{1, 3},
LI Xiaoming^{1, 3
, ,}

1.
Department of Preventive Medicine, School of Public Health, North China University of Science and Technology, Tangshan 063210, China
2.
Department of Internal Medicine, North China University of Science and Technology Hospital, Tangshan 063210, China
3.
Hebei Key Laboratory of Occupational Health and Safety for Coal Industry, Tangshan 063210, China
4.
Department of Epidemiology and Biostatistics, School of Public Health Xi′an Jiaotong University, Xi′an 710061, China

Funds:

National Key Research and Development Program of China 2016YFC0900605

STI2030-Major Projects 2021ZD0200700

Science Research Project of Hebei Education Department QN2019190

Science and Technology Research Project of Tangshan City 22130234H

More Information

Corresponding author: LI Xiaoming, E-mail: lxmxxh@163.com

摘要

摘要: 目的探讨童年不良经历(adverse childhood experiences, ACEs)对中老年人共病患病的影响，并进一步分析不健康生活方式在两者关系中的中介效应。方法选取2011―2018年中国健康与养老追踪调查队列中的7 513名年龄≥45岁的个体作为研究对象。收集研究对象的年龄和性别等基本资料、ACEs情况、不健康生活方式及慢性非传染性疾病患病资料。采用t检验或χ²检验比较不同特征的中老年人共病患病情况差异，采用非条件logistic回归分析ACEs和不健康生活方式对中老年人共病患病的影响，采用Bootstrap程序检验中介效应。结果 7 513名研究对象共病患病率为36.34%(95% CI: 35.25%~37.44%)。多因素分析显示，每增加1种ACEs，中老年人共病患病风险增加10.4%(95% CI: 1.058~1.152)；与经历1种ACEs的中老年人相比，经历3种和≥4种ACEs的中老年人共病患病风险分别增加38.3%(95% CI: 1.023~1.870)和43.2%(95% CI: 1.065~1.926)；每增加1种不健康生活方式，中老年人共病患病风险增加14.4%(95% CI: 1.077~1.216)。与有健康生活方式的中老年人相比，存在≥4种不健康生活方式的中老年人共病患病风险增加99.1%(95% CI: 1.365~2.903)。中介效应分析发现，不健康生活方式的中介效应均无统计学意义(均P>0.05)。结论 ACEs与中老年人共病患病呈正相关，尚未发现不健康生活方式在中老年人ACEs和共病关联中起中介作用。
- 童年不良经历 /
- 不健康生活方式 /
- 共病 /
- 中老年人 /
- 中介作用
Abstract: Objective This study aimed to examine the association between adverse childhood experiences (ACEs) and multimorbidity in middle-aged and older adults, and to investigate whether unhealthy lifestyle mediates this relationship. Methods We analyzed data from 7 513 participants aged ≥45 years in the China Health and Retirement Longitudinal Study from 2011 to 2018. Demographic characteristics, ACEs exposure, unhealthy lifestyle behaviors and chronic disease diagnoses were assessed. Group differences in multimorbidity prevalence were evaluated using t-tests or χ² tests. Unconditional logistic regression models quantified the effects of ACEs and lifestyle on multimorbidity. Mediation analysis was conducted using the Bootstrap method. Results The prevalence of multimorbidity among the 7 513 participants was 36.34% (95% CI: 35.25%-37.44%). Multivariate analysis revealed that each additional ACE was associated with an 10.4% increase in the risk of multimorbidity (95% CI: 1.058-1.152). Compared to individuals with one ACE, those with 3 and ≥4 ACEs had 38.3% (95% CI: 1.023-1.870) and 43.2% (95% CI: 1.065-1.926) higher risks of multimorbidity, respectively. Additionally, each additional unhealthy lifestyle behavior increased multimorbidity risk by 14.4% (95% CI: 1.077-1.216). Compared to those with healthy lifestyles, individuals with ≥4 unhealthy behaviors had a 99.1% higher risk (95% CI: 1.365-2.903). Mediation analysis revealed that unhealthy lifestyle did not have a significant mediating effect on multimorbidity in middle-aged and older adults (all P>0.05) Conclusions ACEs were positively correlated with multimorbidity, no significant mediating role of an unhealthy lifestyle was found between ACEs and multimorbidity among middle-aged and older adults.
- Adverse childhood experiences /
- Unhealthy lifestyle /
- Multimorbidity /
- Middle-aged and elderly individuals /
- Mediating effect

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图 1 不健康生活方式在ACEs和共病关联中的中介效应路径图

ACEs: 童年不良经历。

Figure 1. Path diagram of the mediation effect of unhealthy lifestyles in the association between ACEs and multimorbidity

ACEs: adverse childhood experiences.

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表 1 研究对象基本特征

Table 1. Basic characteristics of the study participants

变量 Variable	例数 Number of examples	共病 Multimorbidity^②		患病率 Prevalence/%	t/χ²值 value	P值 value
变量 Variable	例数 Number of examples	否 No	是 Yes	患病率 Prevalence/%	t/χ²值 value	P值 value
年龄/岁 Age/years^①	7 513	63.09±8.97	64.73±8.95		7.635	< 0.001
性别 Gender					1.744	0.187
男 Male	3 590	2 313(48.36)	1 277(46.78)	35.57
女 Female	3 923	2 470(51.64)	1 453(53.22)	37.04
民族 Ethnicity					8.156	0.004
汉 Han	6 996	4 484(93.75)	2 512(92.01)	35.91
少数民族 Ethnic minority	517	299(6.25)	218(7.99)	42.17
婚姻状况 Marital status					3.461	0.063
已婚 Married	5 881	3 776(78.95)	2 105(77.11)	35.79
其他 Other	1 632	1 007(21.05)	625(22.89)	38.30
文化程度 Education					4.951	0.175
小学以下 Primary school	3 333	2 082(43.53)	1 251(45.82)	37.53
小学 Primary school	1 593	1 013(21.18)	580(21.25)	36.41
初中 Middle	1 689	1 111(23.23)	587(21.50)	34.75
高中及以上 Senior high school or up	889	577(12.06)	312(11.43)	35.10
居住地 Residence					1.008	0.315
农村 Rural	4 934	3 161(66.09)	1 773(64.95)	35.93
城市 Urban	2 579	1 622(33.91)	957(35.05)	37.11
职业 Occupation					7.729	0.005
农业 Agricultural	4 767	2 979(62.28)	1 788(65.49)	37.51
非农业 Non-agricultural	2 746	1 804(37.72)	942(34.51)	34.30
自评健康 Self-rated health					308.342	< 0.001
好 Good	2 076	1 649(34.48)	427(15.64)	20.57
差 Poor	5 437	3 134(65.52)	2 303(84.36)	42.36
家庭人均支出水平 The level of expenditure per household					4.643	0.031
低 Low	4 819	3 111(65.04)	1 708(62.56)	35.44
高 High	2 694	1 672(34.96)	1 022(37.44)	37.94
吸烟 Smoking					4.869	0.027
否 No	5 111	3 211(67.13)	1 900(69.60)	37.17
是 Yes	2 402	1 572(32.87)	830(30.40)	34.55
饮酒 Drinking					4.092	0.043
否 No	5 185	3 262(68.20)	1 923(70.44)	37.09
是 Yes	2 328	1 521(31.80)	807(29.56)	34.66
BMI/(kg·m^-2)					52.801	< 0.001
< 18.5	464	305(6.38)	159(5.82)	34.27
18.5~＜24.0	4 280	2 861(59.81)	1 419(51.98)	33.15
≥24.0	2 769	1 617(33.81)	1 152(42.20)	41.60
睡眠时间 Sleep time/h					15.399	< 0.001
< 7	2 873	1 750(36.59)	1 123(41.13)	39.09
7~8	1 555	1 023(21.39)	532(19.49)	34.21
>8	3 085	2 010(42.02)	1 075(39.38)	34.84
注：①以x±s表示；②以人数(占比/%)表示。 Note: ① x±s; ② Number of people(proportion/%).

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表 2 不同童年不良经历的中老年人共病患病情况比较

Table 2. Comparison of multimorbidity prevalence among middle-aged and elderly adults with different adverse childhood experiences

变量 Variable	例数 Number of examples	共病 Multimorbidity^①		患病率 Prevalence/%	χ²值 value	P值 value
变量 Variable	例数 Number of examples	否 No	是 Yes	患病率 Prevalence/%	χ²值 value	P值 value
感到孤独 Feel alone					11.878	0.001
是 Yes	1 504	900(18.82)	604(22.12)	40.16
否 No	6 009	3 883(81.18)	2 126(77.88)	35.38
欺凌 Bullying					3.745	0.053
是 Yes	1 070	653(13.65)	417(15.27)	38.97
否 No	6 443	4 130(86.35)	2 313(84.73)	35.90
和父母关系 Relationship with parents					0.037	0.848
坏 Poor	1 730	1 098(22.96)	632(23.15)	36.53
好 Good	5 783	3 685(77.04)	2 098(76.85)	36.28
和邻居关系 Relationship with neighbors					7.637	0.006
坏 Poor	1 025	613(12.82)	412(15.09)	40.20
好 Good	6 488	4 170(87.18)	2 318(84.91)	35.73
和朋友关系 Relationship with friends					2.649	0.104
坏 Poor	3 809	2 391(49.99)	1 418(51.94)	37.23
好 Good	3 704	2 392(50.01)	1 312(48.06)	35.42
自我报告健康状况 Self-reported health					5.197	0.023
坏 Poor	771	462(9.66)	309(11.32)	40.08
好 Good	6 742	4 321(90.34)	2 421(88.68)	35.91
健康限制 Health limitation					16.231	< 0.001
是 Yes	541	301(6.29)	240(8.79)	44.36
否 No	6 972	4 482(93.71)	2 490(91.21)	35.71
父母去世 Death of parents					7.036	0.008
是 Yes	1 342	812(16.98)	530(19.41)	39.49
否 No	6 171	3 971(83.02)	2 200(80.59)	35.65
兄弟姐妹去世 Death of siblings					2.064	0.151
是 Yes	1 454	902(18.86)	552(20.22)	37.96
否 No	6 059	3 881(81.14)	2 178(79.78)	35.95
身体虐待 Physical abuse					1.667	0.197
是 Yes	2 143	1 340(28.02)	803(29.41)	37.47
否 No	5 370	3 443(71.98)	1 927(70.59)	35.88
父母精神问题 Parents mental health					17.836	< 0.001
是 Yes	1 470	866(18.11)	604(22.12)	41.09
否 No	6 043	3 917(81.89)	2 126(77.88)	35.18
饥饿 Hunger					39.070	< 0.001
是 Yes	5 660	3 491(72.99)	2 169(79.45)	38.32
否 No	1 853	1 292(27.01)	561(20.55)	30.28
童年社区安全 Childhood neighborhood safety					7.766	0.005
坏 Poor	609	356(7.44)	253(9.27)	41.54
好 Good	6 904	4 427(92.56)	2 477(90.73)	35.88
家庭暴力 Domestic violence					11.919	0.001
是 Yes	486	274(5.73)	212(7.77)	43.62
否 No	7 027	4 509(94.27)	2 518(92.23)	35.83
父母分居或离婚 Parental separation or divorce					1.704	0.192
是 Yes	51	28(0.59)	23(0.84)	45.10
否 No	7 462	4 755(99.41)	2 707(99.16)	36.28
注：①以人数(占比/%)表示。 Note: ① Number of people(proportion/%).

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表 3 ACEs与共病关联的多因素分析

Table 3. Multivariate analysis of the association between ACEs and multimorbidity

ACEs	模型1 Model 1		模型2 Model 2		模型3 Model 3
ACEs	OR值 value (95% CI)	P值 value	OR值 value (95% CI)	P值 value	OR值 value (95% CI)	P值 value
ACEs	1.123(1.078~1.169)	< 0.001	1.096(1.050~1.143)	0.001	1.104(1.058~1.152)	0.001
0	1.000		1.000		1.000
1	1.076 (0.797~1.453)	0.634	1.017(0.747~1.384)	0.915	1.015(0.744~1.384)	0.927
2	1.351 (1.010~1.807)	0.042	1.246(0.924~1.679)	0.149	1.256(0.930~1.696)	0.137
3	1.477 (1.104~1.976)	0.009	1.355(1.004~1.828)	0.047	1.383(1.023~1.870)	0.035
≥4	1.590 (1.197~2.112)	0.001	1.401(1.044~1.880)	0.025	1.432(1.065~1.926)	0.017
注：ACEs，童年不良经历；模型1调整年龄与性别；模型2调整年龄、性别、民族、婚姻状况、文化程度、居住地、职业、自评健康和家庭人均支出水平；模型3在模型2的基础上调整了吸烟、饮酒、BMI和睡眠时间。 Note: ACEs, adverse childhood experiences; Model 1 adjusted for age and gender; Model 2 adjusted for age, gender, ethnicity, marital status, education level, residence, occupation, self-rated health, and per capita household expenditure; Model 3 further adjusted for smoking, drinking, BMI, and sleep status, based on model 2.

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表 4 不健康生活方式与中老年人共病患病的logistic回归分析

Table 4. Logistic regression analysis of unhealthy lifestyles and multimorbidity among middle-aged and elderly adults

不健康生活方式得分 Unhealthy lifestyle score	模型1 Model 1		模型2 Model 2		模型3 Model 3
不健康生活方式得分 Unhealthy lifestyle score	OR值 value (95% CI)	P值 value	OR值 value (95% CI)	P值 value	OR值 value (95% CI)	P值 value
得分 Score	1.141(1.075~1.210)	< 0.001	1.142(1.075~1.213)	< 0.001	1.144(1.077~1.216)	< 0.001
0	1.000		1.000		1.000
1	1.204(0.981~1.477)	0.075	1.186(0.963~1.462)	0.108	1.177(0.955~1.451)	0.126
2	1.429(1.167~1.750)	0.001	1.413(1.148~1.737)	0.001	1.407(1.143~1.731)	0.001
3	1.411(1.114~1.787)	0.004	1.395(1.096~1.776)	0.007	1.397(1.097~1.779)	0.007
≥4	1.972(1.366~2.847)	< 0.001	1.993(1.367~2.905)	< 0.001	1.991(1.365~2.903)	< 0.001
注：模型1调整年龄与性别；模型2调整年龄、性别、民族、婚姻状况、文化程度、居住地、职业、自评健康和家庭人均支出水平；模型3在模型2的基础上调整了ACEs。 Note: Model 1 adjusted for age and gender; Model 2 adjusted for age, gender, ethnicity, marital status, education level, residence, occupation, self-rated health, and per capita household expenditure; Model 3 further adjusted for ACEs, based on model 2.

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表 5 BMI在ACEs和共病关联中的间接效应检验

Table 5. Test of the indirect effect of BMI in the association between ACEs and multimorbidity

效应类型 Effect type	中介效应值 Point estimate	Boot标准误Bootstrap s_x	95% CI	P值 value
总效应 Total effect	0.019 3	0.004 6	(0.010 2~0.028 4)	< 0.001
直接效应 Direct effect	0.021 2	0.004 6	(0.012 1~0.030 3)	< 0.001
间接效应 Indirect effect	-0.001 9	0.000 5	(-0.003 0~-0.000 9)	< 0.001
注：ACEs，童年不良经历。 Note: ACEs, adverse childhood experiences.

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