Eating Behaviors 38 (2020) 101404

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Eating Behaviors
journal homepage: www.elsevier.com/locate/eatbeh

Adverse childhood experiences and fruit and vegetable intake among older
adults in JapanT

Natsuyo Yanagia,1, Yosuke Inoueb,c,⁎,1, Takeo Fujiwarad, Andrew Stickleye, Toshiyuki Ojimaf,
Akira Hataa, Katsunori Kondog,haDepartment of Public Health, Chiba University Graduate School of Medicine, Chiba, Japan
Carolina Population Center, The University of North Carolina at Chapel Hill, NC, USAc
Department of Epidemiology and Prevention, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japand
Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japane
Department of Health Education and Health Sociology, School of Public Health, The University of Tokyo, Tokyo, Japanf
Department of Community Health and Preventive Medicine, Hamamatsu University School of Medicine, Shizuoka, Japang
Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, Chiba, JapanhNational Center for Geriatrics and Gerontology, Aichi, Japanb

ARTICLE INFOABSTRACT

Keywords:
Adverse childhood experience
Fruit and vegetable intake
Older people
Life course

Background: Although adverse childhood experiences (ACEs) have been linked to negative health behaviors in
adulthood, few studies have investigated if the impact continues until late adulthood. We examined the association between ACEs and fruit and vegetable intake (FVI) among older adults in Japan.
Methods: Data came from the Japan Gerontological Evaluation Study (JAGES), 2013 in which 24,271 individuals aged ≥65 years participated. The number of ACEs was calculated (0, 1 and ≥2) while low FVI was
defined as consuming fruit and vegetables less than once a day. A sex-stratified multilevel Poisson regression
analysis was used to investigate the association between ACEs and low FVI.
Results: Among men, 35.4% reported at least one ACE while the corresponding figure for women was 30.6%.
Compared to those without ACEs, the prevalence ratios for low FVI among those who reported ≥2 ACEs were1.51 (95% confidence interval [CI] = 1.30–1.75) for women and 1.28 (95% CI = 1.14–1.44) for men after
adjusting for age and childhood economic hardship. Although these associations were attenuated after adjustingfor socio-demographic and health-related variables, the link between ACEs and low FVI remained statisticallysignificant among women. Of the seven individual forms of ACE, psychological neglect was significantly associated with low FVI (PR = 1.16, 95% CI = 1.03–1.31) among women in the final model.
Conclusions: ACEs are associated with low FVI among older Japanese adults. Our results suggest that the detrimental effect of ACEs on health behavior may stretch across the life course.

1. Introduction
Adverse childhood experiences (ACEs), which include child maltreatment and household dysfunction, have been associated with a wide
range of negative physical and mental health outcomes later in life
(Felitti et al., 1998; Hughes et al., 2017) including mortality (Brown
et al., 2009; Chen, Turiano, Mroczek, & Miller, 2016), cardiovasculardiseases (Appleton, Holdsworth, Ryan, & Tracy, 2017; Jakubowski,
Cundiff, & Matthews, 2018), cancer (Holman et al., 2016), obesity(Palmisano, Innamorati, & Vanderlinden, 2016), type 2 diabetes(Huang et al., 2015), and depression (Li, D'Arcy, & Meng, 2016). While
it is uncertain what underlies the association between ACEs and poorer
health in adulthood, several lifestyle factors might act as mediators,e.g., smoking and alcohol consumption (Felitti et al., 1998; Hughes
et al., 2017).
There is also some evidence that ACEs might be linked to diet in
adulthood (Palmisano et al., 2016). In particular, fruit and vegetableintake (FVI) is an important modifiable lifestyle-related factor of noncommunicable diseases which has been shown to be associated with
ACEs. Previous studies conducted in the UK among adults aged 18 to 70

Corresponding author at: Department of Prevention and Epidemiology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 1628655, Japan.
E-mail address: yosuke.yoshi.yosky@gmail.com (Y. Inoue).
1
These authors contributed equally to this work.
⁎https://doi.org/10.1016/j.eatbeh.2020.101404
Received 27 August 2019; Received in revised form 30 May 2020; Accepted 5 June 2020
Available online 08 June 2020
1471-0153/ © 2020 Published by Elsevier Ltd.

Eating Behaviors 38 (2020) 101404

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reported for example, that the cumulative number of ACEs was positively associated with low FVI (Bellis, Hughes, Leckenby, Perkins, &Lowey, 2014; Bellis, Lowey, Leckenby, Hughes, & Harrison, 2014). Thisis important as other research has also shown that FVI may be associated with a reduced risk of the above-mentioned health outcomes inboth younger and older adults (Boeing et al., 2012; Lo, Chang,
Wahlqvist, Huang, & Lee, 2012; Wang et al., 2014). A recent metaanalysis that used information from 142 articles found that FVI was
associated with a reduced risk of all-cause mortality, cancer and cardiovascular diseases (Aune et al., 2017).
In this study, we examined the association between ACEs and FVI
among the older adult population in Japan. There are several reasons
why this research may be important. First, although previous studies
have examined the association between ACEs and negative healthoutcomes among older adults, there has been comparatively little research in relation to FVI. Second, given the rapid population aging inJapan (Tamiya et al., 2011; United Nations and Department of
Economic and Social Affairs, 2015), efforts should be made to identify
factors that are associated with non-communicable diseases and potential modifiable risk factors. Third, FVI is low among the older population aged 70 and above in Japan; only one-third of them consume
the level of FVI (i.e., 350 g per day of vegetables and 200 g per day offruit) recommended by the Japanese authorities (Ministry of Health,Labour and Welfare, 2020; Ministry of Agriculture, Forestry and
Fisheries, 2019). Given this, an increased understanding of the factorsthat are associated with low FVI among older adults in Japan may offera starting point for the design and implementation of measures to address this deficit.
The purpose of this study was to thus investigate the association
between ACEs and FVI among older Japanese adults using data fromthe Japan Gerontological Evaluation Study (JAGES).

or more frequently” and “less than once a day”.
2.3. Adverse childhood experiences
Similar to previous studies (Felitti et al., 1998), participants wereasked about whether they had experienced different types of adversity
before the age of 18 years old (yes/no). These seven adverse experiences were grouped under two main rubrics: family dysfunction (parent's death, parents' divorce, parental mental illness, domestic violence[DV]) and childhood maltreatment (physical abuse, psychologicalabuse, psychological neglect). These questions have been used previously in other studies using the JAGES data set (Amemiya et al., 2019;
Amemiya, Fujiwara, Murayama, Tani, & Kondo, 2018; Inoue et al.,2019; Isumi et al., 2020; Matsuyama et al., 2016). Following the lead of
Amemiya et al. (2018) and given the small number of participants with
≥3 ACE episodes (1.8%), the number of ACEs was summed and categorized into the following groups (i.e., 0; 1; and ≥2).
2.4. Covariates
Information was also collected on socio-demographic factors, thechildhood environment and current health status: age (divided into four
categories: 65–69; 70–74; 75–79; and 80 and above); sex (male; female); educational attainment (the number of years of schooling: <10[junior high school or less]; 10–12 [high school]; ≥13 years [attained
further education]); longest-held occupation (non-manual [professional, technical or managerial work]; manual [clerical, sales/service,skilled/labor, agriculture/forestry/fishery workers or other]; no occupation); annual equivalized household income (<2.00; 2.00–3.99;≥4.00 million yen; 1 US dollar = 98.4 yen as of October 1, 2013);
marital status (married; widowed; divorced; never married); living arrangement (living alone at home; living with someone at home; other).
Childhood circumstances were assessed with a question that inquired about childhood economic hardship before the age of 18 (yes;no). Regarding health status, experiencing any limitations in higherlevel functional capacity was assessed with the Tokyo Metropolitan
Institute of Gerontology Index of Competence (no limitations, havesome limitations) (Koyano, Shibata, Nakazato, Haga, & Suyama, 1991).
Depressive symptoms were assessed with the Japanese version of theGeriatric Depression Scale (GDS-15) (Wada et al., 2005). Participants
were categorized into three groups: no depressive symptoms (score0–4), mild depressive symptoms (score 5–9), and severe depressive
symptoms (score 10–15).

2. Methods
2.1. Data and participants
We used data from community-dwelling adults aged 65 years orolder living in 31 municipalities across Japan who participated in
JAGES, 2013 (Kondo, 2016; Kondo & Rosenberg, 2018). A self-reportquestionnaire was mailed to 193,694 eligible residents (those who were
not receiving public long-term care insurance) during the period between October and December 2013 with 137,736 individuals responding (a response rate of 71.1%). Due to questionnaire size limitations, information on ACEs was randomly collected from one in every
five participants (n = 26,229). After excluding respondents needing
help for daily living and those who provided no information on thismatter (n = 1958), the final analytic sample comprised 24,271 individuals.
The JAGES study protocol was approved by the Ethics Committee
on Research of Human Subjects at Nihon Fukushi University (No. 1314). The survey's aims and methods were explained in the document
mailed to participants and informed consent was assumed with thevoluntary return of the questionnaire.

2.5. Statistical analyses
We used multiple imputation to account for missing data on ACEs,
FVI, education, occupation, income, marital status, living arrangement,functional capacity, depressive symptoms, and childhood economic
hardship. The imputation used information on age and sex, which did
not have any missing cases. We generated 20 data sets and combined
the results using Rubin's rules (Rubin, 1987). After we found that theinteraction between sex and ACEs was significant (p = 0.022), a sexstratified multilevel Poisson regression analysis with a robust varianceestimator was used to investigate the association between ACEs andcurrent low FVI. We adjusted for clustering by municipality by incorporating a random intercept at the municipality level (i.e. Level 1:
individual participants; Level 2: municipality).
Analyses were performed in the following order. Model 1 investigated the association between ACEs and low FVI while adjusting
for age. Model 2 further adjusted for childhood economic hardship. We
then adjusted for socio-demographic and health-related variables to see
if the association between ACEs and low FVI changed. Specifically,
Model 3 included the same variables as in Model 2 while additionallyadjusting for indicators of adult socioeconomic status (SES) (i.e., education, longest-held occupation and current equivalized annual

2.2. Fruit and vegetable intake
The frequency of FVI was assessed by asking the question “Howoften did you eat fruit and vegetables over the past month?”. This
question has been previously used among older adults in Japan (Taniet al., 2015; Yanagi, Hata, Kondo, & Fujiwara, 2018). Response options
included: “twice a day or more frequently”; “once a day”; “four to six
times a week”; “two or three times a week”; “once a week”; “less thanonce a week”; and “not at all”. Following the lead of previous studies(Atkins et al., 2015; Osler, Godtfredsen, & Prescott, 2008; Sauvaget,
Nagano, Allen, & Kodama, 2003), we categorized the participants into
two groups, i.e., those who consumed fruit and vegetables “once a day2

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Table 1
Total participant characteristics (n = 24,271), stratified by sex.
Total(n = 24,271)

Male(n = 11,268)

Female(n = 13,003)

p-ValueAge (year), n (%)
65–69
70–74
75–79
≥80

7040
7370
5364
4497

29.0
30.4
22.1
18.5

3370
3386
2464
2048

29.9
30.1
21.9
18.2

3670
3984
2900
2449

28.2
30.6
22.3
18.8

0.036

Education (years), n (%)
<10
10–12
≥13
Missing

9780
9060
4991
440

40.3
37.3
20.6
1.8

4197
3959
2953
159

37.3
35.1
26.2
1.4

5583
5101
2038
281

42.9
39.2
15.7
2.2

<0.0015179
14,992
1146
2954

21.3
61.8
4.7
12.2

3890
6387
43
948

34.5
56.7
0.4
8.4

1289
8605
1103
2006

9.9
66.2
8.5
15.4

<0.001

Equivalized annual household income (million yena), n (%)
Low (<2.00)
10,064
Middle (2.00–3.99)
7546
High (≥4.00)
2081
Missing
4580

41.5
31.1
8.6
18.9

4756
3909
1072
1531

42.2
34.7
9.5
13.6

5308
3637
1009
3049

40.8
28.0
7.8
23.5

<0.001

Marital status, n (%)
MarriedWidowedDivorced
Never married
Missing

17,293
4951
807
503
717

71.3
20.4
3.3
2.1
3.0

9637
837
291
218
285

85.5
7.4
2.6
1.9
2.5

7656
4114
516
285
432

58.9
31.6
4.0
2.2
3.3

<0.001

Living arrangement, n (%)
Alone at home
With someone at home
Other
Missing

3270
19,506
351
1144

13.5
80.4
1.5
4.7

924
9703
180
461

8.2
86.1
1.6
4.1

2346
9803
171
683

18.0
75.4
1.3
5.3

<0.001

Limitations in higher level functional capacity, n (%)
No limitations
9432
Has limitations
13,193
Missing
1646

38.9
54.4
6.8

3533
7083
652

31.4
62.9
5.8

5899
6110
994

45.4
47.0
7.6

<0.001

Depressive symptom (GDS scale/points), n (%)
No depression (0–4)
15,203
Mild depression (5–9)
3827
Severe depression (10–15)
1143
Missing
4098

62.6
15.8
4.7
16.9

7303
1929
588
1448

64.8
17.1
5.2
12.9

7900
1898
555
2650

60.8
14.6
4.3
20.4

<0.001Frequency of fruit and vegetable intake, n (%)≥1/day18,872<1/day5040
Missing
359

77.8
20.8
1.5

8096
2995
177

71.9
26.6
1.6

10,776
2045
182

82.9
15.7
1.4

<0.001Childhood economic hardship, n (%)
No
YesMissing

12,185
10,791
1295

50.2
44.5
5.3

4900
5762
606

43.5
51.1
5.4

7285
5029
689

56.0
38.7
5.3

<0.001

Types of adverse childhood experience, n (%)
Parent's death5732
Parents' divorce
528
Parent's mental illness
174
Domestic violence
879
Physical abuse
311
Psychological abuse
1254
Psychological neglect
2722

23.6
2.2
0.7
3.6
1.3
5.2
11.2

2668
274
98
479
218
638
1498

23.7
2.4
0.9
4.3
1.9
5.7
13.3

3064
254
76
400
93
616
1224

23.6
2.0
0.6
3.1
0.7
4.7
9.4

0.26
0.030
0.023
<0.001<0.001<0.001<0.001

Number of childhood adversities, n (%)
013,642
1
6356
≥2
1612
Missing
2661

56.2
26.2
6.6
11.0

6048
3098
893
1229

53.7
27.5
7.9
10.9

7594
3258
719
1432

58.4
25.1
5.5
11.0

<0.001Longest-held occupation, n (%)
Non-manual
ManualNo occupation
Missinga

1 US dollar = 98.4 yen, as of October 1, 2013.

3

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Table 2
Results of a sex-stratified Poisson regression analysis examining the associations between the number of adverse childhood experiences and low fruit and vegetableintake among older Japanese adults.
Model 1PR

Model 2Model 3Model 4Model 5

95% CIPR

95% CIPR

95% CIPR

95% CIPR

95% CIMen
ACEs (ref. none)
1
1.17
≥2
1.34

1.08–1.27
1.20–1.50

1.14
1.28

1.06–1.24
1.14–1.44

1.09
1.17

1.01–1.18
1.04–1.31

1.07
1.10

0.99–1.16
0.98–1.23

1.06
1.04

0.97–1.14
0.92–1.17

Women
ACEs (ref. none)
1
1.18
≥2
1.64

1.07–1.30
1.42–1.89

1.14
1.51

1.03–1.25
1.30–1.75

1.08
1.36

0.97–1.19
1.17–1.58

1.05
1.27

0.95–1.16
1.10–1.48

1.04
1.18

0.94–1.15
1.01–1.37

ACEs: adverse childhood experiences CI: confidence interval; PR: prevalence ratio.
Model 1: adjusted for age.
Model 2: Model 1 + adjusted for childhood economic hardship.
Model 3: Model 2 + adjusted for education, longest occupation, annual equivalized household income.
Model 4: Model 3 + adjusted for marital status, living arrangements, functional limitations.
Model 5: Model 4 + adjusted for depressive symptoms.

adjustment by adult SES (Model 3) and marital status, current living
situation and functional limitations (Model 4) attenuated these results.
Among women, domestic violence (PR = 1.33, 95% CI = 1.07–1.64),
physical abuse (PR = 1.57, 95% CI = 1.08–2.27), psychological abuse(PR = 1.22, 95% CI = 1.03–1.46) and psychological neglect(PR = 1.45, 95% CI = 1.29–1.64) were associated with low FVI in
Model 2. In the fully adjusted Model 5 only psychological neglect
continued to be significantly associated with low FVI.

household income). Model 4 included the same variables as in Model 3
as well as marital status, living arrangements and the presence of limitations in higher-level functional capacity. The fully adjusted Model 5
included the same variables as in Model 4 with the addition of depressive symptoms. An inspection of the variance inflation factors (VIF)
indicated that there was no significant multicollinearity among thevariables.
To identify specific types of ACE that might be more strongly associated with low FVI, we also analyzed the association between eachindividual ACE and FVI using the above-mentioned models. All analyses
were performed using Stata ver. 15.0 (Stata Corp, College Station, TX).
The results are presented as prevalence ratios (PR) with 95% confidence
intervals (CI). Statistical significance was set at p < 0.05 (two-tailed).

4. Discussion
This study found that both men and women who experienced ACEs
had a significantly increased risk for low FVI in late adulthood compared to those without ACEs, with more pronounced associations observed among women. The association among women, although attenuated, remained statistically significant even after adjusting forchildhood economic hardship, adult SES, marital status, current living
situation, functional limitations and depressive symptoms. Moreover,
our results indicate that psychological neglect in childhood might beespecially important in this context. Overall, the findings of this study
suggest that ACEs may have a long-lasting effect on health-related behavior that might even stretch into late adulthood.
Our finding that ACEs were linked to an increased risk for low FVI isin line with those reported in previous studies. For example, Bellis,
Lowey, et al. (2014) found that among a sample of 1464 participants(age: 18–70 years), those who reported 4 or more ACEs had a 2.10
times higher risk of low FVI, compared to those without ACEs; thisfinding has been replicated in other studies by the same authors using
different datasets (Bellis et al., 2017; Bellis, Hughes, et al., 2014). Our
study builds on and extends this previous research that examined theassociation among participants with a wide age range (18–70 years
old), by showing that ACEs are associated with low FVI even when the
research is restricted to much older adults; this indicates that ACEs may
be important for dietary behavior even in the oldest age groups.
Previous studies have suggested that several mechanisms might link
ACEs and poorer health behaviors such as low FVI. For example, research has indicated that ACEs may cause structural and functionalchanges to the brain (e.g., reduced volume in the prefrontal cortex) that
may have a negative, long-lasting effect on executive function (Danese& McEwen, 2012; Kelder, Akker, Geurts, Lindauer, & Overbeek, 2018);
in turn, executive dysfunction may result in a less healthy lifestyle as aresult, for example, of choosing immediate rewards (e.g., energy densefood) instead of large delayed rewards (e.g. health) (Barlow, Reeves,
McKee, Galea, & Stuckler, 2016). Other research has hypothesized thatthose who experienced ACEs may have lacked childhood role models

3. Results
The mean age of the participants was 73.7 (standard deviation[SD] = 6.1) and 53.6% of them were women. Table 1 shows the sociodemographic characteristics of the participants stratified by sex. Amongmen, 26.6% consumed fruit and vegetables less than once a day, while
the corresponding figure for women was 15.7%. Just over 35% of men(35.4%) reported at least one ACE while the figure for women was
30.6%.
Table 2 shows the results of a sex-stratified multilevel Poisson regression analysis which investigated the association between ACEs andlow FVI. Among men, having more than one ACE was significantly
associated with low FVI in Model 1 (≥2 ACEs: PR = 1.34, 95%
CI = 1.20–1.50) and remained statistically significant in Model 2. The
inclusion of the socio-demographic and health-related variables attenuated the association, which became non-significant after adjustingfor marital status, living arrangements and functional limitations inModel 4. For women, experiencing more than one ACE was significantly
associated with low FVI in Model 1 (≥2 ACEs: PR = 1.64, 95%
CI = 1.42–1.89). The inclusion of childhood economic hardship (Model2), adult SES (Model 3), marital status, current living situation andfunctional limitations (Model 4) and depressive symptoms (Model 5) all
attenuated the prevalence ratio although the association remained
statistically significant (≥2 ACEs: PR = 1.18, 95% CI = 1.01–1.37 inModel 5).
Table 3 presents the results of a sex-stratified multilevel Poisson
regression model that examined the association between each individual ACE item and low FVI. Among men, parental death(PR = 1.12, 95% CI = 1.03–1.21) and psychological neglect(PR = 1.23, 95% CI = 1.12–1.35) were associated with low FVI after
adjusting for age and childhood economic hardship (Model 2). Further
4

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Table 3Results of a sex-stratified Poisson regression analysis examining the associations between individual childhood adversities and low fruit and vegetable intake amongolder Japanese adults.
Model 1Model 2Model 3Model 4Model 5PR

95% CIPR

95% CIPR

95% CIPR

95% CIPR

95% CI

Men
Parent's deathParents' divorce
Parent's mental illness
Domestic violence
Physical abuse
Psychological abuse
Psychological neglect

1.15
1.27
1.20
1.17
1.27
1.14
1.26

1.06–1.25
1.04–1.54
0.86–1.67
1.00–1.38b
1.02–1.58
1.00–1.31c
1.15–1.38

1.12
1.21
1.15
1.12
1.21
1.10
1.23

1.03–1.21
1.00–1.48a
0.82–1.61
0.95–1.31
0.97–1.51
0.96–1.26
1.12–1.35

1.07
1.15
1.06
1.09
1.10
1.06
1.12

0.99–1.16
0.94–1.39
0.76–1.48
0.92–1.28
0.88–1.37
0.93–1.22
1.02–1.24

1.06
1.13
1.02
1.06
1.05
1.02
1.08

0.98–1.15
0.93–1.38
0.73–1.42
0.90–1.25
0.84–1.31
0.89–1.17
0.98–1.18

1.05
1.11
1.00
1.02
0.99
0.97
1.02

0.97–1.14
0.91–1.35
0.72–1.40
0.87–1.20
0.79–1.24
0.84–1.12
0.93–1.12

Women
Parent's deathParents' divorce
Parent's mental illness
Domestic violence
Physical abuse
Psychological abuse
Psychological neglect

1.13
1.37
1.23
1.44
1.73
1.31
1.51

1.02–1.25
1.06–1.77
0.77–1.97
1.17–1.78
1.20–2.50
1.10–1.56
1.34–1.71

1.08
1.29
1.12
1.33
1.57
1.22
1.45

0.97–1.20
1.00–1.66d
0.70–1.80
1.07–1.64
1.08–2.27
1.03–1.46
1.29–1.64

1.04
1.20
1.07
1.24
1.39
1.18
1.31

0.94–1.15
0.93–1.54
0.67–1.70
1.01–1.53
0.96–2.02
0.99–1.41
1.16–1.48

1.04
1.17
1.05
1.16
1.27
1.12
1.23

0.94–1.15
0.90–1.51
0.66–1.67
0.94–1.43
0.88–1.84
0.94–1.33
1.09–1.39

1.03
1.13
1.01
1.10
1.13
1.03
1.16

0.93–1.14
0.87–1.46
0.63–1.61
0.89–1.36
0.78–1.65
0.86–1.23
1.03–1.31

CI: confidence interval; PR: prevalence ratio.
Model 1: adjusted for age.
Model 2: Model 1 + adjusted for childhood economic hardship.
Model 3: Model 2 + adjusted for education, longest occupation, annual equivalized household income.
Model 4: Model 3 + adjusted for marital status, living arrangements, functional limitations.
Model 5: Model 4 + adjusted for depressive symptoms.
a
95% CI: 0.996–1.478.
b
95% CI: 0.996–1.378.
c
95% CI: 0.995–1.308.
d95% CI: 0.996–1.658.

that would enable them to develop healthy lifestyles in the period whenhealthy eating habits (Huang et al., 2015; Palmisano et al., 2016) or
cooking habits (Hartmann, Dohle, & Siegrist, 2013) are learnt.
It should be mentioned that other detrimental outcomes that havealso been associated with ACEs, e.g., poor health, depressive symptoms,
low educational attainment, loss of employment and social deprivation(Liu et al., 2013; Wade et al., 2016), might also link ACEs with FVI. For
example, an earlier study showed that ACEs can have a negative impact
on instrumental activities of daily living (which include shopping andcooking) (Amemiya et al., 2018) and cognitive function (Tani,
Fujiwara, & Kondo, 2020). It is possible that the increased risk forfunctional limitations associated with ACEs makes it difficult for someindividuals to buy and/or prepare fruit and vegetables, thus resulting in
low FVI. This supposition gains some support from the attenuated associations between ACEs and low FVI in Model 4 after we included
functional limitations in the analysis. These chains-of-risk may beparticularly important among the older population, for whom the effects of ACEs might have accumulated across the life course.
We found a sex difference in the association between ACEs and FVI,
i.e., more pronounced associations observed among women compared
to men. Several previous studies on the association between ACEs andother health outcomes (e.g., smoking, mental health problems andcancer) have also reported more pronounced associations in women(Alcalá, Tomiyama, & von Ehrenstein, 2017; Cunningham et al., 2014;
Fisher et al., 2009; Fuller-Thomson, Filippelli, & Lue-Crisostomo, 2013;
Haatainen et al., 2003; Isohookana, Riala, Hakko, & Räsänen, 2013).
While no explanation is readily available in relation to the sex difference reported in this study, one possible interpretation based on findings reported in the previous literature is that women are more vulnerable to the effects of ACEs, and thus ACEs might have been more
likely to manifest as negative health behaviors in women compared tomen (Alcalá et al., 2017; Cunningham et al., 2014; Fisher et al., 2009;
Fuller-Thomson et al., 2013; Haatainen et al., 2003; Isohookana et al.,2013). From a different perspective the weaker associations observed

among Japanese men might be related to the fact that they tend to eat
meals that are prepared by their spouse. Consequently, given theirlimited role in all aspects of meal preparation, ACEs might be less important in terms of their own FVI. In addition, as our study population
comprised older adults, it is also possible that those men who experienced ACEs may have been more likely to die prematurely due to negative health behaviors linked to ACEs (i.e., we are observing a survival
effect).
When examining the specific effect of each ACE, we found thatpsychological neglect was the childhood adversity that had the strongest association with the risk of low FVI among women. Although it isuncertain what underlies this association, it can be speculated thatthose who were neglected in childhood may have lacked role models toenable them to develop healthy dietary habits. At the same time, as theeffects of ACEs are known to coexist and accumulate, the potential
contribution of each individual ACE should not be underestimated. It
should also be noted that these analyses were subject to low statisticalpower, and thus caution should be exercised when interpreting thefindings.
One of the strengths of this study is that we were able to collectinformation from 31 municipalities across Japan to ensure the generalizability of the study findings. However, this study also has several
limitations. First, the information on ACEs might not have been accurate; for example, we used self-reported information which means thatreporting bias might have been an issue, especially as the participants
were older (Hardt & Rutter, 2004; Maughan & Rutter, 1997). In addition, there might have been other types of ACEs that we did not ask
about (e.g., sexual abuse) that might have been important for the observed associations. Second, as regards the reporting of fruit and vegetable intake, caution should also be exercised because of the possibility of social desirability bias (Maynard & Blane, 2009). A response toa single question may not have fully captured the actual FVI situation,compared to if the information on FVI had been collected using astandardized food frequency table or food diary. We also lacked
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N. Yanagi, et al.

information on the quantity of FVI. Third, we did not collect information on some variables that may have helped elucidate the association
between ACEs and low FVI (e.g., dietary practices, food delivery services, and cooking skills). Fourth, our findings may be subject to selection bias. Specifically, as individuals with high ACE counts are more
likely to die earlier (Brown et al., 2009), it is possible that those who
were most severely affected by ACEs may have already died and thus
would not have participated in the survey.
There are several directions for future work. First, the focus should
be directed towards the primary prevention of ACEs. In particular, more
effort is needed to identify those at risk of ACEs in the first instance.
Second, as it is also important to understand how to mitigate the detrimental effects of ACEs among those who experience such events, research investigating whether clinical treatment(s) (e.g., neuro-counseling) (Lorelle & Michel, 2017) or changing the neighborhood
environment (e.g., by creating a favorable food environment) (Keyeset al., 2012) can modify the association between ACEs and low FVI isalso warranted. Third, prospective research is now also needed to elucidate how the association between ACEs and low FVI is linked to negative health outcomes such as physical illness, mental illness andmortality. Finally, the reasons for the sex difference in the association
between ACEs and FVI should also be investigated to determine if thismight be linked to factors such as different food cultures, traditionalcustoms, or differences between local communities.

Research and Development Grants for Longevity Science from Japan
Agency for Medical Research and Development (AMED), a grant fromthe Japan Science and Technology Agency (JST; OPERA>JPMJOP1831) and the Fixed Income Fund (AXA Life Insurance Co.,
Ltd.). NY was supported by the Chiba University SEEDS Fund (Chiba
University Open Recruitment for International Exchange Program).
These organizations had no role in the study design, collection, analysis
or interpretation of the data, writing the manuscript, or the decision tosubmit the paper for publication.
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5. Conclusions
We found that among older Japanese adults, those with ACEs weremore likely to report having low FVI, with a stronger association observed among women than men. Future research should focus on not
only the primary prevention of ACEs but also, on the role of FVI as apossible mediator linking ACEs and more severe negative health outcomes.
CRediT authorship contribution statement
Natsuyo Yanagi: Conceptualization, Formal analysis, Writing original draft. Yosuke Inoue: Conceptualization, Formal analysis,
Writing - original draft. Takeo Fujiwara: Conceptualization,
Methodology, Writing - review & editing. Andrew Stickley:Conceptualization, Writing - original draft, Writing - review & editing.
Toshiyuki Ojima: Conceptualization, Funding acquisition, Project administration, Supervision, Writing - review & editing. Akira Hata:
Conceptualization, Supervision, Writing - review & editing. Katsunori
Kondo: Conceptualization, Funding acquisition, Project administration,
Supervision, Writing - review & editing.
Declaration of competing interest
The authors declare that there are no conflicts of interest.
Acknowledgements
This study was financially supported by Health Labour Sciences
Research Grants (H26-Choju-Ippan-006, H25-Choju-Ippan-003, H25Kenki-Wakate-015, H25-Irryo-Shitei-003 (Fukkou), H24-Junkanki(Seishu)-Ippan-007, H24-Choju-Wakate-009, H30-Jyunkanki-Ippan004, 19FA1012, 19FA2001) from the Japanese Ministry of Health,Labour and Welfare, a grant from the Department of Health and Human
Services, Grants-in-Aid for Scientific Research (KAKENHI JP20319338,
JP22390400, JP23243070, JP23590786, JP23790710, JP24390469,
JP24530698, JP24653150, JP24683018, JP25253052, JP25870881,
JP15H01972, JP15H04781, JP20H00557) from the Japan Society for
the Promotion of Science, grants from the National Center for Geriatrics
and Gerontology (24-17, 24-23, J09KF00804), a grant from the6

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