Women with post-traumatic stress disorder are nearly twice as likely to develop type 2 diabetes compared with women who don’t have PTSD, according to researchers at Harvard T.H. Chan School of Public Health and the Mailman School of Public Health at Columbia University.

The longitudinal cohort study provides the strongest evidence to date of a causal relationship between PTSD and type 2 diabetes. Results were published online January 7, 2015 in JAMA Psychiatry.

The researchers analyzed survey data collected between 1989 and 2011 from 49,739 women enrolled in the Nurses’ Health Study II and found a dose-response relationship: the greater the number and severity of PTSD symptoms, the greater a woman’s risk of type 2 diabetes. Four percent of the nurses reported the highest number of PTSD symptoms By age 60, nearly 12 percent of women with the highest number of PTSD symptoms had developed type 2 diabetes, whereas fewer than 7 percent of women with no trauma exposure had diabetes.

Antidepressant use and elevated body mass index accounted for nearly half of the increased risk of type 2 diabetes, or 34 and 14 percent, respectively. On the other hand, smoking, diet quality, alcohol intake, and physical activity did not explain the association.

One in nine women will have PTSD at sometime over the course of her lifetime—twice the rate of men. Women are also more likely to experience extreme traumatic events like rape that carry a high risk for the disorder.

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