Independent and Mediated Associations of Adverse Childhood Experiences With Overweight and Obesity in Adults From the United States: Insights From the 2023 Behavioral Risk Factor Surveillance System (BRFSS) Data

Adult overweight and obesity remain an urgent public health concern in the United States. While adverse childhood experiences (ACEs) are recognized as risk factors, it remains unclear whether their influence persists independently of adult socioeconomic and behavioral conditions. To our knowledge, this study is among the first to analyze the 2023 Behavioral Risk Factor Surveillance System (BRFSS) data with multilevel modeling to isolate ACE effects from adult risk factors. Using data from the 2023 BRFSS (n=269,521), this study employed multilevel logistic regression to examine the relationship between ACEs and adult overweight/obesity (BMI≥25), adjusting for demographic, socioeconomic, health access, behavioral, and chronic disease variables. ACEs were categorized as 0, 1-2, or ≥3. Out of the total 269,521 respondents, 67.5% (n=182,008) were classified as overweight or obese. Participants with three or more ACEs (n=9,677) had a higher crude prevalence of overweight/obesity (69.7%) compared to those with no ACEs (n=12,786, 67.0%; p=0.02). However, in fully adjusted models, ACEs were not significantly associated with overweight/obesity (OR for ≥3 ACEs=1.08; 95% CI: 0.92-1.27). Independent predictors included race/ethnicity, income, education, physical inactivity, diabetes, and healthcare access. These findings suggest that ACEs may influence obesity indirectly, primarily through their impact on adult socioeconomic and behavioral factors. Interventions that address adult-level risk factors, particularly in populations with high ACE exposure, combined with trauma-informed care, may be more effective in reducing obesity prevalence.