There are additional study limitations. Global Burden of Disease data and PAF methods are each extensively used but have limitations.33,34,35 Criticism of GBD data often refers to countries where health data systems are underdeveloped or incomplete—requiring extensive modeling for complete GBD estimates, which some argue risks undermining incentives to invest in resources to gather real-world data—whereas GBD data sources for US estimates are largely long-standing, relatively comprehensive, and publicly available.36 However, GBD data are also criticized for opaque analytic procedures,33 and this study did not include verification tasks, such as analysis of original GBD sources, to double-check case counts, nor did we delve into contributing details, such as GBD disability weights, used to calculate DALY morbidity. Interpretation of this study’s PAF results as the proportional reduction in average disease risk that could be achieved by eliminating ACE assumes that exposure has been accurately measured in the study population and that unmeasured factors affecting both ACEs and adult health outcomes (eg, childhood socioeconomic status) are less influential than the effect of ACEs on adult health. The ability to control for additional childhood circumstances could reduce the economic estimate values presented herein.
