Early-Life Exposure to the Chinese Famine of 1959–1961 and Type 2 Diabetes in Adulthood: A Systematic Review and Meta-Analysis

Abstract

Background: The fast-growing literature suggests that the Chinese famine of 1959–1961 drives current and future type 2 diabetes (T2D) epidemics in China. This conclusion may be premature, as many Chinese famine studies have major methodological problems. We examine these problems, demonstrate how they bias the study results, and formulate recommendations to improve the quality of future studies. Methods: We searched English and Chinese databases for studies that examined the relationship between prenatal exposure to the Chinese famine and adult T2D from inception to 8 February 2022. We extracted information on T2D cases and study populations of individuals born during the famine (famine births), before the famine (prefamine births), and after the famine (postfamine births). We used random-effects models to compare the odds of T2D in famine births to several control groups, including postfamine births, combined pre- and postfamine births, and prefamine births. We used meta-regressions to examine the impacts of age differences between comparison groups on famine effect estimates and the role of other characteristics, including participant sex, age, and T2D assessments; famine intensity; residence; and publication language. Potential sources of heterogeneity and study quality were also evaluated. Results: Twenty-three studies met our inclusion criteria. The sample sizes ranged from less than 300 to more than 360,000 participants. All studies defined the famine exposure based on the participants’ dates of birth, and 18 studies compared famine births and postfamine births to estimate famine effects on T2D. The famine and postfamine births had an age difference of three years or more in all studies. The estimates of the famine effect varied by the selection of controls. Using postfamine births as controls, the OR for T2D among famine births was 1.50 (95% CI 1.34–1.68); using combined pre- and postfamine births as controls, the OR was 1.12 (95% CI 1.02–1.24); using prefamine births as controls, the OR was 0.89 (95% CI 0.79–1.00). The meta-regressions further showed that the famine effect estimates increased by over 1.05 times with each one-year increase in ignored age differences between famine births and controls. Other newly identified methodological problems included the poorly assessed famine intensity, unsuitable study settings for famine research, and poor confounding adjustment. Interpretation: The current estimates of a positive relationship between prenatal exposure to the Chinese famine and adult T2D are mainly driven by uncontrolled age differences between famine births and postfamine births. Studies with more rigorous methods, including age-balanced controls and robust famine intensity measures, are needed to quantify to what extent the famine exposure is related to current T2D patterns in China.

Effect modification of socioeconomic status on the association of exposure to famine in early life with osteoporosis in women

“…Furthermore, Chinese famine has been studied for more than 10 years. However, there are some methodology problems 24,25 . First, the age difference among groups was the significant limitation.…”

“…Therefore, we used the directed acyclic graphs to guide covariate adjustments (see Supporting information, Figure S1). Furthermore, the quality assessment tool of famine studies was taken into account 25 …”

“…However, there are some methodology problems. 24,25 First, the age difference among groups was the significant limitation. In many diseases, the prevalence increases with age.…”

Association of famine exposure and the serum calcium level in healthy Chinese adults

“…Thirdly, the severity and precise duration of famine exposure, confounding including place of birth and residence, and familial socioeconomic status (SES) at the time of the famine are unknown, thus the potential dose-response relationship between famine and serum calcium has not been studied in our research. A recent review addressed some recommendations that might help improve future Chinese famine studies ( 65 ). Besides, further studies regarding the mediation effect of calcium in famine-related health outcomes are needed.…”

Association between famine exposure in early life and risk of hospitalization for heart failure in adulthood

“…We conducted a series of stratification analyses by sex (men vs. women), economic status (annual income <50,000 vs. ≥ 50,000 yuan), current smoking status (no vs. yes), hypertension (no vs. yes), diabetes (no vs. yes), dyslipidemia (no vs. yes), and BMI (<24 vs. ≥ 24 kg/m 2 ). In the sensitivity analysis, to reduce the age gap between groups, we combined the pre-famine and post-famine groups together as an age-balanced non-exposed group to test the robustness of the main results, as suggested by previous studies ( 10 , 30 , 31 ). All analyses were conducted with R statistical software version 3.33 (R Project for Statistical Computing).…”