Association between adverse childhood experiences and depressive symptoms among college students: the moderating effect of unhealthy lifestyle

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This study aims to investigate the associations of ACEs and lifestyle with depressive symptoms and to analyze the moderating effect of lifestyle on the relationship between ACEs and depressive symptoms among college students. Methods A total of 21,143 college students from Shaanxi Province of China were recruited. The Adverse Childhood Experiences International Questionnaire was used to assess ACEs, and the Self-rating Depression Scale was used to evaluate depressive symptoms. Lifestyle information were collected by a self-report questionnaire. The associations of ACEs and lifestyle with depressive symptoms were analyzed using logistic regression models. Furthermore, we evaluated whether lifestyle modified the effect of ACEs on depressive symptoms. Results The prevalence of depressive symptoms was 15.57%. 82.32% of college students experienced one or more type of ACEs. After adjusting for potential covariates, college students with higher levels of ACEs (≥ 4) had a higher odd of depressive symptoms ( OR , 6.25; 95%CI , 5.42–7.21) compared to those with low levels of ACEs (0–1). An additive interaction between ACEs and lifestyle on depressive symptoms was found. There would be a 5.25 ( RERI , 5.25; 95%CI , 1.91–8.60) relative excess risk because of the additive interaction in participants with high levels of ACEs accompanied by an unhealthy lifestyle, which accounted for 37% (AP, 0.37; 95% CI , 0.19–0.54) of the odds of depressive symptoms. Conclusions Lifestyle interventions may be effective in preventing depressive symptoms among college students who have already experienced ACEs. Depressive symptoms Adverse childhood experiences Lifestyle College students Figures Figure 1 Figure 2 1. Introduction Depression is a widespread mental disorder around the world. According to the prediction of the World Health Organization(WHO) [ 1 ] , depression is set to become the primary cause of the global disease burden by 2030. Depressive symptoms are the core components of the clinical diagnosis of depression, which is very common in adolescence [ 2 ] . College students are in the critical transitional phase between adolescence and adulthood, and the developmental characteristics make college students more susceptible to external pressures such as academic pressure, social anxiety, employment pressure, and other external stressors. Prior studies indicated that depressive symptoms were quite prevalent among college students [ 3 , 4 ] , having rates ranging from 18.0–55.2%. More crucially, despite the implementation of several therapies, there has no discernible decrease in the worldwide incidence or burden of depressive symptoms after 1990 [ 5 ] . The need for a deeper understanding of the factors that influence depressive symptoms among college students has never been more urgent so that the health system can respond appropriately. Numerous factors, such as genetic, psychological, physiological, and other factors, have been recognized as possible triggers of depressive symptoms [ 6 , 7 ] . Adverse childhood experiences (ACEs) refer to distressing and/or traumatic events that take place during childhood, such as child abuse, neglect, and family dysfunction [ 8 , 9 ] . As reported, more than half of the global population has experienced ACEs [ 10 ] . Notely, several studies have identified ACEs as a ‘toxic stress’ that significantly contributes to the emergence and advancement of psychological disorders [ 11 – 13 ] . Profound clinical observations and cohort research demonstrated that ACEs was a significant predictor of depressive symptoms [ 14 , 15 ] . Growing evidence suggested that chronic and repeated exposure to ACEs could persistently stimulate the hypothalamic-pituitary-adrenal (HPA) axis [ 16 ] . Dysregulation of the HPA axis will increase cortisol and inflammatory markers in the body, which can have a variety of impacts on the brain, endocrine, and immunological systems, and thus on depressive symptoms. Since different forms of ACEs often occur simultaneously, the combined impacts of different types of ACEs may intensify the influence on depressive symptoms. Therefore, exploring any specific ACE may somewhat overestimate its impact. Analyzing the connection between different types of ACEs and depressive symptoms among college students could provide a more comprehensive evaluation of the extent of childhood trauma. However, the research addressing the influence of multiple ACEs on depressive symptoms in college students is insufficient. Furthermore, certain health-related habits such as smoking, alcohol usage, and unhealthy diets were often established during adolescence. Recent research has shown compelling evidence that an unhealthy lifestyle is significant risk factor for both mental and physical diseases [ 17 , 18 ] . These lifestyles may potentially influence one other in clusters rather than operating independently. Thus, integrating several lifestyle behaviors as lifestyle risk indicators is more theoretical. Moreover, while individuals with more unhealthy lifestyles may be more susceptible to the negative consequences of toxic exposure, it remains uncertain if an unhealthy lifestyle worsens the effect of ACEs on depressive symptoms. Some studies have shown that both unhealthy lifestyles and ACEs are associated with immune dysregulation [ 19 , 20 ] , which was found having an important impact on depressive symptoms. So, it can be hypothesized that unhealthy lifestyles might worsen the relationship between ACEs and depressive symptoms. Therefore, the current study aims to analyze the connections of ACEs and health-related lifestyle risk index with depressive symptoms among college students. Additionally, we also investigated the combined impact of ACEs and lifestyle on depressive symptoms. 2. Methods 2.1 Study design and participants We selected a university in Shaanxi Province (Northwest China) using a convenient sampling method. A total of 22,047 college students in the university were invited to join the study from October to November 2022. Before the investigation, we conducted a survey training for the counselors of all classes in this college, and the class counselors trained and assisted all students to complete the structured questionnaire anonymously. Rapid response code (QR code) was given to students and the students scanned the QR code to complete this survey. For quality control, three calculation and single-choice questions were also included in the structured questionnaire. The average time for completing the questionnaire was 27 minutes. After removing invalid questionnaires completed in less than 500 seconds and at least one logical question answered incorrectly, we retained a total of 21,143 students for the final analysis (Fig. 1). Ethical approval was obtained from the Ethics Committee of The Second Affiliated Hospital of Xi’an Jiaotong University (Approval number: 2022 − 248), and participants provided electronic informed consent. This study was conducted in compliance with the principles outlined in the Declaration of Helsinki. 2.2 Measures 2.2.1 ACEs ACEs were assessed using the Adverse Childhood Experiences International Questionnaire (ACE-IQ) constructed by the WHO [ 8 ] . The questionnaire covers 13 domains, including physical abuse, emotional abuse, sexual abuse, family substance use, family incarceration, family mental illness, domestic violence, parental death or separation, emotional neglect, physical neglect, bullying, community violence, and collective violence. The ACE-IQ was translated by Ho et al. and demonstrated its high level of reliability and validity in Chinese [ 21 ] . In the present investigation, the Cronbach's α coefficient for the ACE-IQ was 0.74. For each domain in this study, an answer of ‘ever’ meant experienced a type of ACEs, and the sum of the 13 domains was the total number of ACEs types, which varied from 0 to 13. Based on prior research and the distribution of ACEs in this study [ 22 , 23 ] , we categorized individuals into three groups: low levels of ACEs (0–1 types), intermediate levels of ACEs (2–3 types), and high levels of ACEs (≥ 4 types). 2.2.2 Depressive symptoms The depressive symptoms were evaluated by the Self-rating Depression Scale (SDS) [ 24 ] . The SDS consists of 20 items that are rated from 1 (never or very infrequent) to 4 (most or all of the time). These items represent the participants' depressive symptoms during the last week. We obtain a standardized score by multiplying the total SDS score by 1.25. Individuals with a standard score more than 50 were identified as having depressive symptoms [ 25 ] . The Cronbach α coefficient for the SDS in this study was 0.88. 2.2.3 Lifestyle As reported in previous studies [ 26 , 27 ] , unhealthy lifestyle factors included current smoking, current alcohol drinking, insufficient physical activity, unhealthy diet, and abnormal weight (obesity or underweight) (Supplementary Table S1 ). Participants who had smoked one or more cigarettes in the previous 30 days were considered current smokers. Current drinkers are categorized as drinking at least one glass of wine in the past 30 days. Physical activity was assessed using the International Physical Activity Questionnaire Short Form, which classifies individuals into low, moderate, and high level of physical activity [ 28 ] . Within this investigation, the low level of physical activity means unhealthy physical activity. The body mass index (BMI) was determined by dividing the body weight by the square of the height, with underweight and obesity defined as BMI below 18.5 kg/m 2 and above 28 kg/m 2 , respectively. In line with prior research, an unhealthy diet was characterized as individuals eating red meat or eating vegetables/fruits less than once a day [ 27 ] . One point is scored for each lifestyle defined as unhealthy. The combined score was the lifestyle risk index, also known as the unhealthy lifestyle score, with a range of 0 to 5. Based on prior research and the distribution of unhealthy lifestyle scores in the current study [ 29 ] , participants were categorized into three groups: favorable lifestyle (0–1 score), intermediate lifestyle, (2 score), unhealthy lifestyle (≥ 3 score). 2.2.4 Covariates This study included demographic and socioeconomic features as covariates. Social and demographic variables such as gender, grade level, race, registered permanent residence, siblings, and parental educational achievement were gathered using a self-designed general information questionnaire. 2.3 Statistical Analysis All data were implemented in R 4.0.2 software ( https://www.r-project.org/ ). The distributions of the various features were calculated using the χ 2 test or t- test. The odds ratio ( OR ) and 95% confidence interval ( CI ) of depressive symptoms with ACEs and lifestyles were estimated using two logistic regression models. Model 1 is the crude model without adjusting for any factors. For model 2, gender, grade, race, siblings, registered permanent residence, and parental educational achievement were adjusted. We examined the correlation between the number of ACEs types and depressive symptoms. Then, the categories of ACEs were used to investigate possible nonlinear correlations between ACEs and depressive symptoms. Furthermore, we employed a logistic regression model to estimate the correlation between lifestyle and depressive symptoms. Then, by categorizing the participants into 9 groups based on ACEs and lifestyle condition, we also examined the effect of ACEs and lifestyle on the risk of depressive symptoms, with low ACEs and healthy lifestyle as a comparison. The relative excess risk due to the interaction (RERI) and the attributable proportion due to the interaction (AP) were used to evaluated the ‘ACEs × lifestyle’ interaction [ 30 ] . The following formulas were used for the RERI and AP calculations [ 31 ] : RERI = RERI 11 -RERI 10 -RERI 01 + 1; AP = RERI/RR 11 . Both the CIs for RERI and AP contained 0 indicating no obvious interaction. 3. Results Table 1 displays the basic features of the study population. This survey included 21,143 college students, 34.59% were male, 56.83% were urban residents, and 34.44% came from one-child family. A 15.57% prevalence of depressive symptoms was observed. 82.32% of college students reported encountering at least one type of ACEs, while 14.46% reported experiencing at least four types of ACEs. Table 1 Characteristics of participants according to depressive symptoms. Characteristics Total participants Depressive symptoms P no yes Gender, n (%) < 0.001 Male 7313(34.59) 6270(85.74) 1043(14.26) Female 13830(65.41) 11579(83.72) 2251(16.28) Grade, n (%) < 0.001 1st 7174(33.93) 6042(84.22) 1132(15.78) 2nd 5483(25.93) 4482(81.74) 1001(18.26) 3rd 5524(26.13) 4726(85.55) 798(14.45) 4th+ 2962(14.01) 2599(87.74) 363(12.26) Race, n (%) 0.053 Han 20269(95.87) 17132(84.52) 3137(15.48) Others 874(4.13) 717(82.04) 157(17.96) Registered permanent residence, n (%) 0.748 Rural 9128(43.17) 7697(84.32) 1431(15.68) Urban 12015(56.83) 10152(84.49) 1863(15.51) Siblings, n (%) 0.087 No 7281(34.44) 6190(85.01) 1091(14.99) Yes 13862(65.56) 11659(84.11) 2203(15.89) Maternal educational attainment, n (%) 0.001 Middle school or under 11749(55.57) 9828(83.65) 1921(16.35) High school 4926(23.30) 4235(85.97) 691(14.03) College or above 4468(21.13) 3786(84.74) 682(15.26) Parental educational attainment, n (%) < 0.001 Middle school or under 10209(48.29) 8530(82.54) 1679(17.46) High school 5192(24.55) 4468(84.10) 724(15.90) College or above 5742(27.16) 4851(85.23) 891(14.77) Unhealthy lifestyle, n (%) < 0.001 Healthy 2598(12.29) 2344(90.22) 254(9.78) Intermediate 15202(71.90) 12964(85.28) 2238(14.72) Unhealthy 3343(15.81) 2541(76.01) 802(23.99) Number of ACEs types, n (%) 0 ~ 1 3738(17.68) 3452(92.35) 286(7.65) < 0.001 2 ~ 3 14347(67.86) 12376(86.26) 1971(13.74) ≥ 4 3058(14.46) 2021(66.09) 1037(33.91) The prevalence of depressive symptoms was higher among college students who had experienced different types of ACEs (Fig. 2 and Supplementary Table S1 ). In Table 2 , we aggregated the cumulative ACEs types as an exposure variable and examined its correlation with depressive symptoms. After controlling for demographic and socioeconomic features (gender, grade, race, registered permanent residence, sibship, and parental education), each incremental type in ACEs was strongly linked to increased risks of depressive symptoms ( OR , 1.33; 95%CI , 1.30–1.35) (Table 2 , Model 2). Then, we classified participants into three groups based on ACEs types to investigate possible nonlinear correlation. After controlling for demographic and socioeconomic features, the risk of depressive symptoms among individuals with higher levels of ACEs (≥ 4) ( OR , 6.25; 95%CI , 5.42–7.21) and intermediate levels ACEs (2 ~ 3) ( OR , 1.96; 95%CI , 1.72–2.24) were higher than those with low levels ACEs (0–1)(Table 2 , Model2). As shown in Table 3 , logistic regression analysis demonstrated statistically obvious correlations between lifestyle and depressive symptoms. More precisely, after adjustment for potential covariates, those who with unhealthy lifestyle had a higher risk of depressive symptoms ( OR , 3.15; 95% CI , 2.70–3.69) compared to those who with healthy lifestyle (Table 2 , Model 2). Table 2 Association between ACEs and depressive symptoms. ACEs OR(95% CI) Model 1 Model 2 Each unit increases 1.33(1.30, 1.36) 1.33(1.30, 1.35) Low levels(0 ~ 1) 1[Reference] 1[Reference] Intermediate levels(2 ~ 3) 1.92(1.69, 2.19) 1.96(1.72, 2.24) High levels (≥ 4) 6.19(5.37, 7.14) 6.25(5.42, 7.21) OR, odds ratio; CI, confidence interval; Model 1, crude model. Model 2, adjustment for gender, grade, race, registered permanent residence, siblings, and parental educational attainment. Table 3 Association between lifestyle and depressive symptoms. Lifestyle OR(95% CI) Model 1 Model 2 Each unit increases 1.38(1.33, 1.44) 1.43(1.37, 1.48) Healthy(0 ~ 1) 1[Reference] 1[Reference] Intermediate(2) 1.59(1.39, 1.83) 1.59(1.38, 1.82) Unhealthy(≥ 3) 2.91(2.50, 3.39) 3.15(2.70, 3.69) OR, odds ratio; CI, confidence interval; Model 1, crude model. Model 2, adjustment for gender, grade, race, registered permanent residence, siblings, and parental educational attainment. Table 4 Joint effect of ACEs and lifestyle on the prevalence of depressive symptoms. Number of ACEs types Lifestyle OR(95%CI) RERI(95%CI) AP(95%CI) Low levels(0 ~ 1) Healthy 1[Reference] Low levels(0 ~ 1) Intermediate 1.59(1.09, 2.32) Low levels(0 ~ 1) Unhealthy 3.00(1.88, 4.81) Intermediate levels(2 ~ 3) Healthy 1.98(1.34, 2.91) Intermediate levels(2 ~ 3) Intermediate 2.99(2.10, 4.27) 0.43(-0.54, 0.91) 0.14(-0.04, 0.33) Intermediate levels(2 ~ 3) Unhealthy 5.48(3.79, 7.91) 1.50(0.33, 2.67) 0.27(0.07, 0.48) High levels (≥ 4) Healthy 7.08(4.54, 11.05) High levels (≥ 4) Intermediate 9.32(6.48, 13.39) 1.64(-0.51, 3.79) 0.18(-0.50, 0.40) High levels (≥ 4) Unhealthy 14.34(9.81, 20.98) 5.25(1.91, 8.60) 0.37(0.19, 0.54) OR, odds ratio; CI, confidence interval; RERI, relative excess risk due to the interaction; AP, attributable proportion due the interaction. Adjusted for gender, grade, race, registered permanent residence, siblings and parental educational attainment. Furthermore, we found a dose-response combined effect of unhealthy lifestyle and ACEs on the risk of depressive symptoms. More specifically, compared to those with low levels of ACEs and healthy lifestyle, individuals with intermediate levels of ACEs and unhealthy lifestyle had a significantly higher risk of depressive symptoms ( OR , 5.48; 95%CI , 3.79–7.91). Conversely, individuals with high levels of ACEs and unhealthy lifestyles had the highest odds of depressive symptoms ( OR , 14.34; 95%CI , 9.81–20.98). Additionally, the prevalence of depressive symptoms was found to be positively influenced by the additive interactions of ACEs with unhealthy lifestyle. In participants with intermediate levels of ACEs accompanied by unhealthy lifestyle, the RERI was 1.50( RERI , 1.50; 95%CI , 0.33–2.67) for depressive symptoms, which suggested that there would be a 1.50 relative excess risk because of the additive interaction. It accounted for 27% ( AP , 0.27; 95%CI , 0.07–0.48) of the odds of depressive symptoms in participants exposed to both intermediate ACEs and unhealthy lifestyles. In participants with high levels of ACEs accompanied by unhealthy lifestyle, the RERI was 5.25( RERI , 5.25; 95%CI , 1.91–8.60) for depressive symptoms, which suggested that there would be a 5.25 relative excess risk because of the additive interaction, accounting for 37% ( AP , 0.37; 95%CI , 0.19–0.54) of the odds of depressive symptoms in participants exposed to both high levels of ACEs and unhealthy lifestyles. 4. Discussion In the current school-based survey, we found that both individual and cumulative ACEs and unhealthy lifestyles were associated with a higher risk of depressive symptoms among college students. Moreover, when we examined the combined impact of lifestyle and ACEs, we discovered that individuals with high levels of ACEs and unhealthy lifestyles had the biggest increase in risk of depressive symptoms. This study provides additional evidence for the impact of the combined interaction between lifestyle and ACEs on depressive symptoms. The correlation between ACEs and depressive symptoms is receiving increasing attention. The current investigation revealed a substantial association between exposure to ACEs and postpartum depressive symptoms. These findings align with prior research documented in the literature [ 15 , 32 ] . Among the 13 types of ACEs, peer bullying was found having the greatest impact on college students' depressive symptoms. In adolescence, peer relationships are the most important social connections. Exposure to peer bullying can drastically reduce their interactions with peers, thereby leading to impaired social support. In addition, childhood is a critical period of psychological development, and bullying can greatly increase the victim's self-denial and increase the risk of depressive symptoms [ 33 ] . The toxic stress theory is the most prominent and comprehensive mechanism explaining the impact of ACEs on depressive symptoms [ 34 ] . According to the theory, exposure to severe, frequent, or protracted challenges during childhood can activate a physiological reaction called ‘toxic stress’. This reaction will trigger abnormal and persistent stimulation of the HPA axis, resulting in the release and accumulation of high levels of cortisol in the circulatory system [ 35 ] . Excessive cortisol thus fosters the generation of free radicals and exerts stress on the neurological, cardiovascular, endocrine, and immunological systems, finally influencing depressive symptoms [ 36 ] . A prior investigation demonstrated that depressive symptoms are also affected by the dysregulation of postsynaptic 5-hydroxytryptamine receptor 1A (5-HT1A) and 5-hydroxytryptamine receptor 2A (5-HT2A), which can be triggered by severe stress [ 37 ] . It further explains the influence of ACEs on depressive symptoms. Additionally, a study from the Münster Neuroimaging Cohort Study suggested that ACEs have a detrimental effect on insular surface area, thereby raising the risk of unfavorable disease progression in depressive symptoms [ 38 ] . Another study also found that those who experience emotional neglect during childhood exhibit a smaller white matter volume in the hippocampus [ 39 ] . This also implied that these individuals may be more susceptible to psychiatric problems associated with stress in their later years. Overall, this research indicated that alterations in the brain may be accountable for the influence of ACEs on depressive symptoms. Evidence from the present study supported the dose-response correlations between diverse types of ACEs exposure and depressive symptoms among college students, which is consistent with previous studies conducted in different regions and populations. A prospective cohort study revealed that for each additional type of ACEs [ 15 ] , the risk of depressive symptoms in children and adolescents increased substantially by 65%. Another cross-sectional study also found that the risk of depressive symptoms in adolescents exposed to 2 and 4 types of ACEs was 2.07 and 5.77 times higher than adolescents who did not experience ACEs [ 40 ] . Furthermore, there was a notable positive correlation between the cumulative exposure to ACEs and the increased risk of depressive symptoms. While, the studies mentioned above mostly examined the impact of ACEs on depressive symptoms in children and adolescents, research on young adults is currently lacking, particularly college students. According to the cumulative stressors model [ 41 ] , when individuals are exposed to many and severe ACEs, they will build psychological adaptations that reduce their resistance and raise the risk of depressive symptoms. The present study provided further evidence on the impact of ACEs exposures on depressive symptoms among college students, both independent and cumulative. This finding has important implications for the prevention and protection of depressive symptoms among college students. The causes of depressive symptoms in college students are complex. Both previous studies and the present study have clarified the effects of ACEs on depressive symptoms, and further identification of modifiable factors between ACEs and depressive symptoms is important to stop or alleviate the adverse effects of ACEs. A meta review evaluated the available data on the influence of lifestyle on the risk and therapy for various mental health problems, such as depressive symptoms [ 42 ] . The study revealed that unhealthy lifestyle intensify psychological difficulties, while healthy lifestyle can alleviate them. A more recent study has presented compelling evidence that a healthy lifestyle is correlated with a 57% decrease in the incidence of depressive symptoms, as compared to unhealthy lifestyle [ 43 ] . However, studies on the modification effects of lifestyle on the association between ACEs and depressive symptoms are still scarce. In this population-based investigation, we gathered comprehensive data on lifestyle to investigate the potential relationship. Our observation revealed a combined impact of unhealthy lifestyle and ACEs on the risk of depressive symptoms, which followed a dose-response pattern. Additionally, the statistical significance of the interactions between ACEs and lifestyles on the risk of depressive symptoms suggests that individuals who adopt unhealthy lifestyles in their daily lives may exacerbate the negative impact of ACEs on depressive symptoms. To our knowledge, it was the first study investigating the combined effects of ACEs and lifestyle on depressive symptoms among college students. The precise biological mechanisms responsible for the interaction effects of lifestyle on the connection between ACEs and depressive symptoms are not fully understood. A prior investigation revealed that the effects of unhealthy lifestyle behaviors on disrupted pathways are related to depressive symptoms, and encompass neurotransmitter mechanisms and immuno-inflammatory responses [ 44 ] . Fasciano et al. have reported that insufficient physical exercise leads to the dysregulation of the HPA axis [ 45 ] . Considering the previously established association of unhealthy lifestyle and ACEs with immune dysregulation and dysregulation of the HPA axis [ 19 , 20 , 35 ] , we hypothesize that the immune dysregulation and dysregulation of HPA axis caused by the combination of ACEs and unhealthy lifestyle may be an additional plausible mechanism for the observed interactions. Findings from the present study have important practical implications. Considering that these lifestyles behaviors can be changed and embracing a healthy lifestyle is advantageous for physical health and mental well-being. The adoption of healthy lifestyle by college students can be beneficial in alleviating the negative effects of ACEs, thereby decreasing the risk of depressive symptoms. Moreover, our results could be valuable in developing targeted interventions to mitigate the negative impact of ACEs on depressive symptoms. There exist limitations in this study. Firstly, gathering ACEs and lifestyle information using a self-report questionnaire may lead to recall bias, and people with poor mental health may recall more ACEs than the general population. In addition, despite the inclusion of the most significant confounders in this study, its results may have been influenced by residual or unmeasured confounding factors. Furthermore, the cross-sectional study design restricts the ability to establish causal relationships in this study. Finally, only students from all grades and majors in one university were included in this investigation, which would damage the representation of the study population and the extrapolation of these findings. 5. Conclusions The findings highlight the importance of minimizing ACEs during the early stages of life. Moreover, the results demonstrate a connection between ACEs and depressive symptoms, which also indicate that it is possible to deduce depressive symptoms among college students who have already ACEs by improving their healthy lifestyles. Such findings may contribute to the development of targeted interventions aimed at preventing depressive symptoms. Declarations Ethical Approval and consent to participate This study was approved by the Ethics Committee of The Second Affiliated Hospital of Xi’an Jiaotong University (Approval number: 2022 − 248), and all participants provided electronic informed consent indicated that they agreed to participate and publish. This study was conducted in accordance with the principles of the Declaration of Helsinki. Funding The Key Research and Development Program of Shaanxi Province (No.2020SF-173) and The Natural Science Basic Research Program of Shaanxi (No.2024JC-YBQN-0943) supported this study. Author Contribution JY contributed to the conception or design of the paper and drafted the manuscript. JY, ZSL, MYW and YPZ contributed to the acquisition, analysis, or interpretation of data for the work. MYW and YPZ provided a critical review of the manuscript. All authors reviewed the manuscript. Acknowledgement The authors would like to thank all participants involved in this study. Data Availability Data is provided within the manuscript or supplementary information files References World Health Organization. Depression and other common mental disorders: global health estimates[R]. Geneva: World Health Organization; 2017. Kiviruusu O, Ranta K, Lindgren M, et al. Mental health after the COVID-19 pandemic among Finnish youth: a repeated, cross-sectional, population-based study [J]. Lancet Psychiatry. 2024;11(6):451–60. Li W, Zhao Z, Chen D, et al. Prevalence and associated factors of depression and anxiety symptoms among college students: a systematic review and meta-analysis [J]. 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Li R, Chambless L. Test for additive interaction in proportional hazards models [J]. Ann Epidemiol. 2007;17(3):227–36. Assmann SF, Hosmer DW, Lemeshow S, et al. Confidence intervals for measures of interaction [J]. Epidemiology. 1996;7(3):286–90. Azúa Fuentes E, Rojas Carvallo P, Ruiz Poblete S. Bullying as a risk factor for depression and suicide [J]. Revista Chil de Pediatria. 2020;91(3):432–9. Anderson JR, Mayes TL, Fuller A, et al. Experiencing bullying's impact on adolescent depression and anxiety: Mediating role of adolescent resilience [J]. J Affect Disord. 2022;310:477–83. Del Giudice M. Early stress and human behavioral development: emerging evolutionary perspectives [J]. J Dev Orig Health Dis. 2014;5(4):270–80. Du J, Wang Y, Hunter R, et al. Dynamic regulation of mitochondrial function by glucocorticoids [J]. Proc Natl Acad Sci USA. 2009;106(9):3543–8. Turesky TK, Jensen SKG, Yu X, et al. The relationship between biological and psychosocial risk factors and resting-state functional connectivity in 2-month-old Bangladeshi infants: A feasibility and pilot study [J]. Dev Sci. 2019;22(5):e12841. Juruena MF, Gama CS, Berk M, et al. Improved stress response in bipolar affective disorder with adjunctive spironolactone (mineralocorticoid receptor antagonist): case series [J]. J Psychopharmacol. 2009;23(8):985–7. Opel N, Redlich R, Dohm K, et al. Mediation of the influence of childhood maltreatment on depression relapse by cortical structure: a 2-year longitudinal observational study [J]. Lancet Psychiatry. 2019;6(4):318–26. Frodl T, Reinhold E, Koutsouleris N, et al. Interaction of childhood stress with hippocampus and prefrontal cortex volume reduction in major depression [J]. J Psychiatr Res. 2010;44(13):799–807. Elmore AL, Crouch E. Anxiety, Depression, and Adverse Childhood Experiences: An Update on Risks and Protective Factors Among Children and Youth [J]. Acad Pediatr. 2023;23(4):720–1. Rutter M. Stress, coping and development: some issues and some questions [J]. J Child Psychol Psychiatry. 1981;22(4):323–56. Firth J, Solmi M, Wootton RE, et al. A meta-review of lifestyle psychiatry: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders [J]. World Psychiatry. 2020;19(3):360–80. Yujie Zhao LY, Barbara J, Sahakian C, Langley W, Zhang K, Kuo Z, Li Y, Gan Y, Li Y, Zhao. Jintai Yu, Jianfeng Feng, Wei Cheng The brain structure, immunometabolic and genetic mechanisms underlying the association between lifestyle and depression [J]. Nat Mental Health. 2023;1:736–50. Lopresti AL, Hood SD, Drummond PD. A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise [J]. J Affect Disord. 2013;148(1):12–27. Fasciano LC, Dale LP, Shaikh SK, et al. Relationship of childhood maltreatment, exercise, and emotion regulation to self-esteem, PTSD, and depression symptoms among college students [J]. J Am Coll Health. 2021;69(6):653–9. Additional Declarations No competing interests reported. Supplementary Files 7.supplementarymaterials.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5312131","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371298894,"identity":"a1ac0521-d5d5-4606-97d2-3252c61cf2b7","order_by":0,"name":"Jian Yin","email":"","orcid":"","institution":"Department of Laboratory, The Second Affiliated Hospital of Xi'an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Jian","middleName":"","lastName":"Yin","suffix":""},{"id":371298895,"identity":"828b2384-3ef1-471a-b125-ba3bd928435e","order_by":1,"name":"Mingyang Wu","email":"","orcid":"","institution":"Department of Maternal and Child Health, Xiangya School of Public Health, Central South University","correspondingAuthor":false,"prefix":"","firstName":"Mingyang","middleName":"","lastName":"Wu","suffix":""},{"id":371298896,"identity":"bafe941f-5ca2-4dc5-a463-78e4cc20e8d9","order_by":2,"name":"Peiying Yang","email":"","orcid":"","institution":"Xi'an Jiaotong University School of Public Health, Western China Science and Technology Innovation Harbour","correspondingAuthor":false,"prefix":"","firstName":"Peiying","middleName":"","lastName":"Yang","suffix":""},{"id":371298898,"identity":"af4e6d41-dd8a-4e09-ba7e-744f5c2efb14","order_by":3,"name":"Zeshi Liu","email":"","orcid":"","institution":"Department of Laboratory, The Second Affiliated Hospital of Xi'an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Zeshi","middleName":"","lastName":"Liu","suffix":""},{"id":371298900,"identity":"3b100b12-5961-47ec-b04a-4c984480f942","order_by":4,"name":"Yanping Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYDACZgaGA2CGBIiokJCTJ1HLGQtjwwairQNpYWyrSISagBsYHGd/eJin5o7d/NnNzx5+nSeRwNjA/PDRDTxaJJsZEg7zHHuW3DjnmLmx7DaJPHYGNmPjHDxa+JkZDhzmYTuczCyRYCYtuU2imLGBh00anxY2ZsaGwzz/DiezSaR/k5acI5HYcICAFn5mZobDvG2H7XgkcswkPzYQoUWymY3h4Ny+wwkSEjll0gzHJIwNmwn4xeD88ccf3nw7bC8/I32b5I+aOjl59uaHj/FpAQEmHgaGxAYgg5kHxGUmoBwEGH8wMNjDGKNgFIyCUTAKMAAAnQNJKmwgtpMAAAAASUVORK5CYII=","orcid":"","institution":"Department of Laboratory, The Second Affiliated Hospital of Xi'an Jiaotong University","correspondingAuthor":true,"prefix":"","firstName":"Yanping","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-10-22 13:23:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5312131/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5312131/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69081013,"identity":"495eab08-4efa-4bfc-b4d6-5400d1dee233","added_by":"auto","created_at":"2024-11-15 11:55:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76742,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5312131/v1/36917ce190b119220b255cb7.png"},{"id":69081015,"identity":"26385bf3-df2a-452b-9798-95a09a487355","added_by":"auto","created_at":"2024-11-15 11:55:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":201493,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5312131/v1/51c1079ace9359ac082f426b.png"},{"id":103904337,"identity":"29910dab-3f39-469c-aab4-82fab99e9a13","added_by":"auto","created_at":"2026-03-04 10:28:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1078355,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5312131/v1/7a9ce48c-0409-47a9-b929-e76cc9b724b5.pdf"},{"id":69081014,"identity":"e7bcbf1c-1e41-41ea-b65b-e3c71543f470","added_by":"auto","created_at":"2024-11-15 11:55:45","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15334,"visible":true,"origin":"","legend":"","description":"","filename":"7.supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-5312131/v1/c5519204041aa18177782565.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association between adverse childhood experiences and depressive symptoms among college students: the moderating effect of unhealthy lifestyle","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eDepression is a widespread mental disorder around the world. According to the prediction of the World Health Organization(WHO)\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e, depression is set to become the primary cause of the global disease burden by 2030. Depressive symptoms are the core components of the clinical diagnosis of depression, which is very common in adolescence\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. College students are in the critical transitional phase between adolescence and adulthood, and the developmental characteristics make college students more susceptible to external pressures such as academic pressure, social anxiety, employment pressure, and other external stressors. Prior studies indicated that depressive symptoms were quite prevalent among college students\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e, having rates ranging from 18.0\u0026ndash;55.2%. More crucially, despite the implementation of several therapies, there has no discernible decrease in the worldwide incidence or burden of depressive symptoms after 1990\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. The need for a deeper understanding of the factors that influence depressive symptoms among college students has never been more urgent so that the health system can respond appropriately. Numerous factors, such as genetic, psychological, physiological, and other factors, have been recognized as possible triggers of depressive symptoms\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAdverse childhood experiences (ACEs) refer to distressing and/or traumatic events that take place during childhood, such as child abuse, neglect, and family dysfunction\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. As reported, more than half of the global population has experienced ACEs\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Notely, several studies have identified ACEs as a \u0026lsquo;toxic stress\u0026rsquo; that significantly contributes to the emergence and advancement of psychological disorders\u003csup\u003e[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Profound clinical observations and cohort research demonstrated that ACEs was a significant predictor of depressive symptoms\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Growing evidence suggested that chronic and repeated exposure to ACEs could persistently stimulate the hypothalamic-pituitary-adrenal (HPA) axis\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Dysregulation of the HPA axis will increase cortisol and inflammatory markers in the body, which can have a variety of impacts on the brain, endocrine, and immunological systems, and thus on depressive symptoms. Since different forms of ACEs often occur simultaneously, the combined impacts of different types of ACEs may intensify the influence on depressive symptoms. Therefore, exploring any specific ACE may somewhat overestimate its impact. Analyzing the connection between different types of ACEs and depressive symptoms among college students could provide a more comprehensive evaluation of the extent of childhood trauma. However, the research addressing the influence of multiple ACEs on depressive symptoms in college students is insufficient.\u003c/p\u003e \u003cp\u003eFurthermore, certain health-related habits such as smoking, alcohol usage, and unhealthy diets were often established during adolescence. Recent research has shown compelling evidence that an unhealthy lifestyle is significant risk factor for both mental and physical diseases\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. These lifestyles may potentially influence one other in clusters rather than operating independently. Thus, integrating several lifestyle behaviors as lifestyle risk indicators is more theoretical. Moreover, while individuals with more unhealthy lifestyles may be more susceptible to the negative consequences of toxic exposure, it remains uncertain if an unhealthy lifestyle worsens the effect of ACEs on depressive symptoms. Some studies have shown that both unhealthy lifestyles and ACEs are associated with immune dysregulation\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e, which was found having an important impact on depressive symptoms. So, it can be hypothesized that unhealthy lifestyles might worsen the relationship between ACEs and depressive symptoms.\u003c/p\u003e \u003cp\u003eTherefore, the current study aims to analyze the connections of ACEs and health-related lifestyle risk index with depressive symptoms among college students. Additionally, we also investigated the combined impact of ACEs and lifestyle on depressive symptoms.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design and participants\u003c/h2\u003e \u003cp\u003eWe selected a university in Shaanxi Province (Northwest China) using a convenient sampling method. A total of 22,047 college students in the university were invited to join the study from October to November 2022. Before the investigation, we conducted a survey training for the counselors of all classes in this college, and the class counselors trained and assisted all students to complete the structured questionnaire anonymously. Rapid response code (QR code) was given to students and the students scanned the QR code to complete this survey. For quality control, three calculation and single-choice questions were also included in the structured questionnaire. The average time for completing the questionnaire was 27 minutes.\u003c/p\u003e \u003cp\u003eAfter removing invalid questionnaires completed in less than 500 seconds and at least one logical question answered incorrectly, we retained a total of 21,143 students for the final analysis (Fig.\u0026nbsp;1). Ethical approval was obtained from the Ethics Committee of The Second Affiliated Hospital of Xi\u0026rsquo;an Jiaotong University (Approval number: 2022\u0026thinsp;\u0026minus;\u0026thinsp;248), and participants provided electronic informed consent. This study was conducted in compliance with the principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 ACEs\u003c/h2\u003e \u003cp\u003eACEs were assessed using the Adverse Childhood Experiences International Questionnaire (ACE-IQ) constructed by the WHO\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. The questionnaire covers 13 domains, including physical abuse, emotional abuse, sexual abuse, family substance use, family incarceration, family mental illness, domestic violence, parental death or separation, emotional neglect, physical neglect, bullying, community violence, and collective violence. The ACE-IQ was translated by Ho et al. and demonstrated its high level of reliability and validity in Chinese\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. In the present investigation, the Cronbach's α coefficient for the ACE-IQ was 0.74. For each domain in this study, an answer of \u0026lsquo;ever\u0026rsquo; meant experienced a type of ACEs, and the sum of the 13 domains was the total number of ACEs types, which varied from 0 to 13. Based on prior research and the distribution of ACEs in this study\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e, we categorized individuals into three groups: low levels of ACEs (0\u0026ndash;1 types), intermediate levels of ACEs (2\u0026ndash;3 types), and high levels of ACEs (\u0026ge;\u0026thinsp;4 types).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Depressive symptoms\u003c/h2\u003e \u003cp\u003eThe depressive symptoms were evaluated by the Self-rating Depression Scale (SDS)\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. The SDS consists of 20 items that are rated from 1 (never or very infrequent) to 4 (most or all of the time). These items represent the participants' depressive symptoms during the last week. We obtain a standardized score by multiplying the total SDS score by 1.25. Individuals with a standard score more than 50 were identified as having depressive symptoms\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. The Cronbach α coefficient for the SDS in this study was 0.88.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Lifestyle\u003c/h2\u003e \u003cp\u003eAs reported in previous studies\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e, unhealthy lifestyle factors included current smoking, current alcohol drinking, insufficient physical activity, unhealthy diet, and abnormal weight (obesity or underweight) (Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Participants who had smoked one or more cigarettes in the previous 30 days were considered current smokers. Current drinkers are categorized as drinking at least one glass of wine in the past 30 days. Physical activity was assessed using the International Physical Activity Questionnaire Short Form, which classifies individuals into low, moderate, and high level of physical activity\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. Within this investigation, the low level of physical activity means unhealthy physical activity. The body mass index (BMI) was determined by dividing the body weight by the square of the height, with underweight and obesity defined as BMI below 18.5 kg/m\u003csup\u003e2\u003c/sup\u003e and above 28 kg/m\u003csup\u003e2\u003c/sup\u003e, respectively. In line with prior research, an unhealthy diet was characterized as individuals eating red meat or eating vegetables/fruits less than once a day\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. One point is scored for each lifestyle defined as unhealthy. The combined score was the lifestyle risk index, also known as the unhealthy lifestyle score, with a range of 0 to 5. Based on prior research and the distribution of unhealthy lifestyle scores in the current study\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e, participants were categorized into three groups: favorable lifestyle (0\u0026ndash;1 score), intermediate lifestyle, (2 score), unhealthy lifestyle (\u0026ge;\u0026thinsp;3 score).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.2.4 Covariates\u003c/h2\u003e \u003cp\u003eThis study included demographic and socioeconomic features as covariates. Social and demographic variables such as gender, grade level, race, registered permanent residence, siblings, and parental educational achievement were gathered using a self-designed general information questionnaire.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical Analysis\u003c/h2\u003e \u003cp\u003eAll data were implemented in R 4.0.2 software (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.r-project.org/\u003c/span\u003e\u003cspan address=\"https://www.r-project.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The distributions of the various features were calculated using the \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e test or \u003cem\u003et-\u003c/em\u003etest. The odds ratio (\u003cem\u003eOR\u003c/em\u003e) and 95% confidence interval (\u003cem\u003eCI\u003c/em\u003e) of depressive symptoms with ACEs and lifestyles were estimated using two logistic regression models. Model 1 is the crude model without adjusting for any factors. For model 2, gender, grade, race, siblings, registered permanent residence, and parental educational achievement were adjusted. We examined the correlation between the number of ACEs types and depressive symptoms. Then, the categories of ACEs were used to investigate possible nonlinear correlations between ACEs and depressive symptoms. Furthermore, we employed a logistic regression model to estimate the correlation between lifestyle and depressive symptoms. Then, by categorizing the participants into 9 groups based on ACEs and lifestyle condition, we also examined the effect of ACEs and lifestyle on the risk of depressive symptoms, with low ACEs and healthy lifestyle as a comparison. The relative excess risk due to the interaction (RERI) and the attributable proportion due to the interaction (AP) were used to evaluated the \u0026lsquo;ACEs \u0026times; lifestyle\u0026rsquo; interaction\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. The following formulas were used for the RERI and AP calculations\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e: RERI\u0026thinsp;=\u0026thinsp;RERI\u003csub\u003e11\u003c/sub\u003e-RERI\u003csub\u003e10\u003c/sub\u003e-RERI\u003csub\u003e01\u003c/sub\u003e\u0026thinsp;+\u0026thinsp;1; AP\u0026thinsp;=\u0026thinsp;RERI/RR\u003csub\u003e11\u003c/sub\u003e. Both the CIs for RERI and AP contained 0 indicating no obvious interaction.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the basic features of the study population. This survey included 21,143 college students, 34.59% were male, 56.83% were urban residents, and 34.44% came from one-child family. A 15.57% prevalence of depressive symptoms was observed. 82.32% of college students reported encountering at least one type of ACEs, while 14.46% reported experiencing at least four types of ACEs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of participants according to depressive symptoms.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eDepressive symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7313(34.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6270(85.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1043(14.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13830(65.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11579(83.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2251(16.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7174(33.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6042(84.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1132(15.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5483(25.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4482(81.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1001(18.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5524(26.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4726(85.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e798(14.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4th+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2962(14.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2599(87.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e363(12.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20269(95.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17132(84.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3137(15.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e874(4.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e717(82.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e157(17.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegistered permanent residence, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.748\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9128(43.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7697(84.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1431(15.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12015(56.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10152(84.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1863(15.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSiblings, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7281(34.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6190(85.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1091(14.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13862(65.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11659(84.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2203(15.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal educational attainment, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school or under\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11749(55.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9828(83.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1921(16.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4926(23.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4235(85.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e691(14.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4468(21.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3786(84.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e682(15.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParental educational attainment, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school or under\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10209(48.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8530(82.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1679(17.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5192(24.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4468(84.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e724(15.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5742(27.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4851(85.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e891(14.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnhealthy lifestyle, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2598(12.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2344(90.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e254(9.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15202(71.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12964(85.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2238(14.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnhealthy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3343(15.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2541(76.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e802(23.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of ACEs types, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026thinsp;~\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3738(17.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3452(92.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e286(7.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026thinsp;~\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14347(67.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12376(86.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1971(13.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3058(14.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2021(66.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1037(33.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe prevalence of depressive symptoms was higher among college students who had experienced different types of ACEs (Fig.\u0026nbsp;2 and Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). In Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, we aggregated the cumulative ACEs types as an exposure variable and examined its correlation with depressive symptoms. After controlling for demographic and socioeconomic features (gender, grade, race, registered permanent residence, sibship, and parental education), each incremental type in ACEs was strongly linked to increased risks of depressive symptoms (\u003cem\u003eOR\u003c/em\u003e, 1.33; \u003cem\u003e95%CI\u003c/em\u003e, 1.30\u0026ndash;1.35) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Model 2). Then, we classified participants into three groups based on ACEs types to investigate possible nonlinear correlation. After controlling for demographic and socioeconomic features, the risk of depressive symptoms among individuals with higher levels of ACEs (\u0026ge;\u0026thinsp;4) (\u003cem\u003eOR\u003c/em\u003e, 6.25; \u003cem\u003e95%CI\u003c/em\u003e, 5.42\u0026ndash;7.21) and intermediate levels ACEs (2\u0026thinsp;~\u0026thinsp;3) (\u003cem\u003eOR\u003c/em\u003e, 1.96; \u003cem\u003e95%CI\u003c/em\u003e, 1.72\u0026ndash;2.24) were higher than those with low levels ACEs (0\u0026ndash;1)(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Model2). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, logistic regression analysis demonstrated statistically obvious correlations between lifestyle and depressive symptoms. More precisely, after adjustment for potential covariates, those who with unhealthy lifestyle had a higher risk of depressive symptoms (\u003cem\u003eOR\u003c/em\u003e, 3.15; \u003cem\u003e95% CI\u003c/em\u003e, 2.70\u0026ndash;3.69) compared to those who with healthy lifestyle (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Model 2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between ACEs and depressive symptoms.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eACEs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOR(95% CI)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEach unit increases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.33(1.30, 1.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.33(1.30, 1.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow levels(0\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1[Reference]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1[Reference]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate levels(2\u0026thinsp;~\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.92(1.69, 2.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.96(1.72, 2.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh levels (\u0026ge;\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.19(5.37, 7.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.25(5.42, 7.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eOR, odds ratio; CI, confidence interval;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eModel 1, crude model.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eModel 2, adjustment for gender, grade, race, registered permanent residence, siblings, and parental educational attainment.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between lifestyle and depressive symptoms.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLifestyle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOR(95% CI)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEach unit increases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.38(1.33, 1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.43(1.37, 1.48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthy(0\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1[Reference]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1[Reference]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate(2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.59(1.39, 1.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.59(1.38, 1.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnhealthy(\u0026ge;\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.91(2.50, 3.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.15(2.70, 3.69)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eOR, odds ratio; CI, confidence interval;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eModel 1, crude model.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eModel 2, adjustment for gender, grade, race, registered permanent residence, siblings, and parental educational attainment.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eJoint effect of ACEs and lifestyle on the prevalence of depressive symptoms.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of ACEs types\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLifestyle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eOR(95%CI)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eRERI(95%CI)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eAP(95%CI)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow levels(0\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1[Reference]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow levels(0\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.59(1.09, 2.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow levels(0\u0026thinsp;~\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnhealthy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.00(1.88, 4.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate levels(2\u0026thinsp;~\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.98(1.34, 2.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate levels(2\u0026thinsp;~\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.99(2.10, 4.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43(-0.54, 0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.14(-0.04, 0.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate levels(2\u0026thinsp;~\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnhealthy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.48(3.79, 7.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.50(0.33, 2.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.27(0.07, 0.48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh levels (\u0026ge;\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.08(4.54, 11.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh levels (\u0026ge;\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.32(6.48, 13.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.64(-0.51, 3.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.18(-0.50, 0.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh levels (\u0026ge;\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnhealthy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.34(9.81, 20.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.25(1.91, 8.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.37(0.19, 0.54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eOR, odds ratio; CI, confidence interval; RERI, relative excess risk due to the interaction; AP, attributable proportion due the interaction.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAdjusted for gender, grade, race, registered permanent residence, siblings and parental educational attainment.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFurthermore, we found a dose-response combined effect of unhealthy lifestyle and ACEs on the risk of depressive symptoms. More specifically, compared to those with low levels of ACEs and healthy lifestyle, individuals with intermediate levels of ACEs and unhealthy lifestyle had a significantly higher risk of depressive symptoms (\u003cem\u003eOR\u003c/em\u003e, 5.48; \u003cem\u003e95%CI\u003c/em\u003e, 3.79\u0026ndash;7.91). Conversely, individuals with high levels of ACEs and unhealthy lifestyles had the highest odds of depressive symptoms (\u003cem\u003eOR\u003c/em\u003e, 14.34; \u003cem\u003e95%CI\u003c/em\u003e, 9.81\u0026ndash;20.98). Additionally, the prevalence of depressive symptoms was found to be positively influenced by the additive interactions of ACEs with unhealthy lifestyle. In participants with intermediate levels of ACEs accompanied by unhealthy lifestyle, the RERI was 1.50(\u003cem\u003eRERI\u003c/em\u003e, 1.50; \u003cem\u003e95%CI\u003c/em\u003e, 0.33\u0026ndash;2.67) for depressive symptoms, which suggested that there would be a 1.50 relative excess risk because of the additive interaction. It accounted for 27% (\u003cem\u003eAP\u003c/em\u003e, 0.27; \u003cem\u003e95%CI\u003c/em\u003e, 0.07\u0026ndash;0.48) of the odds of depressive symptoms in participants exposed to both intermediate ACEs and unhealthy lifestyles. In participants with high levels of ACEs accompanied by unhealthy lifestyle, the RERI was 5.25(\u003cem\u003eRERI\u003c/em\u003e, 5.25; \u003cem\u003e95%CI\u003c/em\u003e, 1.91\u0026ndash;8.60) for depressive symptoms, which suggested that there would be a 5.25 relative excess risk because of the additive interaction, accounting for 37% (\u003cem\u003eAP\u003c/em\u003e, 0.37; \u003cem\u003e95%CI\u003c/em\u003e, 0.19\u0026ndash;0.54) of the odds of depressive symptoms in participants exposed to both high levels of ACEs and unhealthy lifestyles.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn the current school-based survey, we found that both individual and cumulative ACEs and unhealthy lifestyles were associated with a higher risk of depressive symptoms among college students. Moreover, when we examined the combined impact of lifestyle and ACEs, we discovered that individuals with high levels of ACEs and unhealthy lifestyles had the biggest increase in risk of depressive symptoms. This study provides additional evidence for the impact of the combined interaction between lifestyle and ACEs on depressive symptoms.\u003c/p\u003e \u003cp\u003eThe correlation between ACEs and depressive symptoms is receiving increasing attention. The current investigation revealed a substantial association between exposure to ACEs and postpartum depressive symptoms. These findings align with prior research documented in the literature\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. Among the 13 types of ACEs, peer bullying was found having the greatest impact on college students' depressive symptoms. In adolescence, peer relationships are the most important social connections. Exposure to peer bullying can drastically reduce their interactions with peers, thereby leading to impaired social support. In addition, childhood is a critical period of psychological development, and bullying can greatly increase the victim's self-denial and increase the risk of depressive symptoms\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. The toxic stress theory is the most prominent and comprehensive mechanism explaining the impact of ACEs on depressive symptoms\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. According to the theory, exposure to severe, frequent, or protracted challenges during childhood can activate a physiological reaction called \u0026lsquo;toxic stress\u0026rsquo;. This reaction will trigger abnormal and persistent stimulation of the HPA axis, resulting in the release and accumulation of high levels of cortisol in the circulatory system\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e. Excessive cortisol thus fosters the generation of free radicals and exerts stress on the neurological, cardiovascular, endocrine, and immunological systems, finally influencing depressive symptoms\u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. A prior investigation demonstrated that depressive symptoms are also affected by the dysregulation of postsynaptic 5-hydroxytryptamine receptor 1A (5-HT1A) and 5-hydroxytryptamine receptor 2A (5-HT2A), which can be triggered by severe stress\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e. It further explains the influence of ACEs on depressive symptoms. Additionally, a study from the M\u0026uuml;nster Neuroimaging Cohort Study suggested that ACEs have a detrimental effect on insular surface area, thereby raising the risk of unfavorable disease progression in depressive symptoms\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e. Another study also found that those who experience emotional neglect during childhood exhibit a smaller white matter volume in the hippocampus\u003csup\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e. This also implied that these individuals may be more susceptible to psychiatric problems associated with stress in their later years. Overall, this research indicated that alterations in the brain may be accountable for the influence of ACEs on depressive symptoms.\u003c/p\u003e \u003cp\u003eEvidence from the present study supported the dose-response correlations between diverse types of ACEs exposure and depressive symptoms among college students, which is consistent with previous studies conducted in different regions and populations. A prospective cohort study revealed that for each additional type of ACEs\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, the risk of depressive symptoms in children and adolescents increased substantially by 65%. Another cross-sectional study also found that the risk of depressive symptoms in adolescents exposed to 2 and 4 types of ACEs was 2.07 and 5.77 times higher than adolescents who did not experience ACEs\u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e. Furthermore, there was a notable positive correlation between the cumulative exposure to ACEs and the increased risk of depressive symptoms. While, the studies mentioned above mostly examined the impact of ACEs on depressive symptoms in children and adolescents, research on young adults is currently lacking, particularly college students. According to the cumulative stressors model\u003csup\u003e[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/sup\u003e, when individuals are exposed to many and severe ACEs, they will build psychological adaptations that reduce their resistance and raise the risk of depressive symptoms. The present study provided further evidence on the impact of ACEs exposures on depressive symptoms among college students, both independent and cumulative. This finding has important implications for the prevention and protection of depressive symptoms among college students.\u003c/p\u003e \u003cp\u003eThe causes of depressive symptoms in college students are complex. Both previous studies and the present study have clarified the effects of ACEs on depressive symptoms, and further identification of modifiable factors between ACEs and depressive symptoms is important to stop or alleviate the adverse effects of ACEs. A meta review evaluated the available data on the influence of lifestyle on the risk and therapy for various mental health problems, such as depressive symptoms\u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e. The study revealed that unhealthy lifestyle intensify psychological difficulties, while healthy lifestyle can alleviate them. A more recent study has presented compelling evidence that a healthy lifestyle is correlated with a 57% decrease in the incidence of depressive symptoms, as compared to unhealthy lifestyle\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e. However, studies on the modification effects of lifestyle on the association between ACEs and depressive symptoms are still scarce. In this population-based investigation, we gathered comprehensive data on lifestyle to investigate the potential relationship. Our observation revealed a combined impact of unhealthy lifestyle and ACEs on the risk of depressive symptoms, which followed a dose-response pattern. Additionally, the statistical significance of the interactions between ACEs and lifestyles on the risk of depressive symptoms suggests that individuals who adopt unhealthy lifestyles in their daily lives may exacerbate the negative impact of ACEs on depressive symptoms. To our knowledge, it was the first study investigating the combined effects of ACEs and lifestyle on depressive symptoms among college students. The precise biological mechanisms responsible for the interaction effects of lifestyle on the connection between ACEs and depressive symptoms are not fully understood. A prior investigation revealed that the effects of unhealthy lifestyle behaviors on disrupted pathways are related to depressive symptoms, and encompass neurotransmitter mechanisms and immuno-inflammatory responses\u003csup\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/sup\u003e. Fasciano et al. have reported that insufficient physical exercise leads to the dysregulation of the HPA axis\u003csup\u003e[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/sup\u003e. Considering the previously established association of unhealthy lifestyle and ACEs with immune dysregulation and dysregulation of the HPA axis\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e, we hypothesize that the immune dysregulation and dysregulation of HPA axis caused by the combination of ACEs and unhealthy lifestyle may be an additional plausible mechanism for the observed interactions.\u003c/p\u003e \u003cp\u003eFindings from the present study have important practical implications. Considering that these lifestyles behaviors can be changed and embracing a healthy lifestyle is advantageous for physical health and mental well-being. The adoption of healthy lifestyle by college students can be beneficial in alleviating the negative effects of ACEs, thereby decreasing the risk of depressive symptoms. Moreover, our results could be valuable in developing targeted interventions to mitigate the negative impact of ACEs on depressive symptoms.\u003c/p\u003e \u003cp\u003eThere exist limitations in this study. Firstly, gathering ACEs and lifestyle information using a self-report questionnaire may lead to recall bias, and people with poor mental health may recall more ACEs than the general population. In addition, despite the inclusion of the most significant confounders in this study, its results may have been influenced by residual or unmeasured confounding factors. Furthermore, the cross-sectional study design restricts the ability to establish causal relationships in this study. Finally, only students from all grades and majors in one university were included in this investigation, which would damage the representation of the study population and the extrapolation of these findings.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThe findings highlight the importance of minimizing ACEs during the early stages of life. Moreover, the results demonstrate a connection between ACEs and depressive symptoms, which also indicate that it is possible to deduce depressive symptoms among college students who have already ACEs by improving their healthy lifestyles. Such findings may contribute to the development of targeted interventions aimed at preventing depressive symptoms.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthical Approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was approved by the Ethics Committee of The Second Affiliated Hospital of Xi\u0026rsquo;an Jiaotong University (Approval number: 2022\u0026thinsp;\u0026minus;\u0026thinsp;248), and all participants provided electronic informed consent indicated that they agreed to participate and publish. This study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe Key Research and Development Program of Shaanxi Province (No.2020SF-173) and The Natural Science Basic Research Program of Shaanxi (No.2024JC-YBQN-0943) supported this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJY contributed to the conception or design of the paper and drafted the manuscript. JY, ZSL, MYW and YPZ contributed to the acquisition, analysis, or interpretation of data for the work. MYW and YPZ provided a critical review of the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank all participants involved in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript or supplementary information files\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Depression and other common mental disorders: global health estimates[R]. Geneva: World Health Organization; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKiviruusu O, Ranta K, Lindgren M, et al. Mental health after the COVID-19 pandemic among Finnish youth: a repeated, cross-sectional, population-based study [J]. Lancet Psychiatry. 2024;11(6):451\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi W, Zhao Z, Chen D, et al. 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J Am Coll Health. 2021;69(6):653\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Depressive symptoms, Adverse childhood experiences, Lifestyle, College students","lastPublishedDoi":"10.21203/rs.3.rs-5312131/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5312131/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eLimited study has reported the effects of adverse childhood experiences (ACEs) and lifestyle on depressive symptoms, especially among college students. This study aims to investigate the associations of ACEs and lifestyle with depressive symptoms and to analyze the moderating effect of lifestyle on the relationship between ACEs and depressive symptoms among college students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 21,143 college students from Shaanxi Province of China were recruited. The Adverse Childhood Experiences International Questionnaire was used to assess ACEs, and the Self-rating Depression Scale was used to evaluate depressive symptoms. Lifestyle information were collected by a self-report questionnaire. The associations of ACEs and lifestyle with depressive symptoms were analyzed using logistic regression models. Furthermore, we evaluated whether lifestyle modified the effect of ACEs on depressive symptoms.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe prevalence of depressive symptoms was 15.57%. 82.32% of college students experienced one or more type of ACEs. After adjusting for potential covariates, college students with higher levels of ACEs (\u0026ge;\u0026thinsp;4) had a higher odd of depressive symptoms (\u003cem\u003eOR\u003c/em\u003e, 6.25; \u003cem\u003e95%CI\u003c/em\u003e, 5.42\u0026ndash;7.21) compared to those with low levels of ACEs (0\u0026ndash;1). An additive interaction between ACEs and lifestyle on depressive symptoms was found. There would be a 5.25 (\u003cem\u003eRERI\u003c/em\u003e, 5.25; \u003cem\u003e95%CI\u003c/em\u003e, 1.91\u0026ndash;8.60) relative excess risk because of the additive interaction in participants with high levels of ACEs accompanied by an unhealthy lifestyle, which accounted for 37% (AP, 0.37; \u003cem\u003e95% CI\u003c/em\u003e, 0.19\u0026ndash;0.54) of the odds of depressive symptoms.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eLifestyle interventions may be effective in preventing depressive symptoms among college students who have already experienced ACEs.\u003c/p\u003e","manuscriptTitle":"Association between adverse childhood experiences and depressive symptoms among college students: the moderating effect of unhealthy lifestyle","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-15 11:55:40","doi":"10.21203/rs.3.rs-5312131/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"763e6521-fd25-413c-af06-60a635c7fb9e","owner":[],"postedDate":"November 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T10:27:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-15 11:55:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5312131","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5312131","identity":"rs-5312131","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}