Risk Factors for Disease Risk Factors and Attributable Risk Calculations: Are There Mathematical Limits?

David W. Brown*, 1, 2, Robert F. Anda1
1 Centers for Disease Control and Prevention, Atlanta, Georgia, USA
2 Netherlands Institute for Health Sciences, Erasmus University Medical Center, Rotterdam, The Netherlands

© 2010Brown et al..

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: ( This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Centers for Disease Control and Prevention, 4770 Buford Highway (K67), Atlanta, Georgia 30341, USA; Tel: +1.770.488.52.69; Fax: +1.770.488.54.65;E-mail:


The Adverse Childhood Experiences (ACE) Study, a collaborative effort between Kaiser Permanente (San Diego, CA) and the Centers for Disease Control and Prevention (Atlanta, GA), was designed to examine the long-term relationship between adverse childhood experiences (ACEs) and a variety of health behaviors and outcomes in adulthood [1]. ACEs include childhood emotional, physical, or sexual abuse and household dysfunction during childhood. The ACE Study, based on chronic disease prevention and control models, proposes that ACEs influence social, emotional, and cognitive impairments which in turn increase the probability of adopting health risk behaviors that have been documented to influence the subsequent development of disease, disability, social problems, and ultimately premature death. We use the ACE pyramid to depict this concept (see