Early life exposure to famine was strongly associated with increased risks of incident type 2 diabetes (T2D) and hypertension, but not cardiovascular hospitalization, according to a population-based cohort study published Nov. 25 in JAMA. These findings indicate that undernutrition early in life is a novel cardiometabolic risk factor among immigrants.

In what they believe is the first study to examine the risks of early life famine exposure in immigrant populations as well as the largest cohort study examining cardiometabolic outcomes of the Great Chinese Famine, Anne Cao, BSc, et al., on behalf of the CV-DIASPORA Investigators, evaluated three cohorts of adult Chinese immigrants aged 20 to 85 years living in Ontario, Canada, from April 1, 1992 to March 31, 2019. Each cohort represented one of the three coprimary outcomes of T2D, hypertension and cardiovascular hospitalization.

Participants were followed up until March 31, 2023, relocation from Ontario or until they reached 85 years of age, whichever occurred first. Data were analyzed from April 22, 2024 to Sept. 30, 2025. Of note, prenatal, childhood and adolescent exposure was classified by birth year (1941-1952), and those born before 1941 or after 1962 served as the comparison group.

The T2D cohort included 188,292 participants (exposed: mean age, 53 years; 53% female; unexposed: mean age, 37 years; 55% female); the hypertension cohort included 180,510 participants (exposed: mean age, 52 years; 52% female; unexposed: mean age, 37 years; 55% female); and the cardiovascular hospitalization cohort included 208,921 participants (exposed: mean age, 51 years; 52% female; comparison: mean age, 38 years; 55% female).

Event rates among the famine-exposed group were 14% for T2D, 30% for hypertension and 2% for cardiovascular hospitalization, showing that early life famine exposure was associated with a 37% to 58% increased hazard of T2D and a 22% to 25% increased hazard of hypertension. Adolescent famine exposure was associated with a 14% decrease in cardiovascular hospitalization, and prenatal and childhood famine were not associated with cardiovascular hospitalization.

The authors note several limitations of this study, including lacking data on place of birth within mainland China, severity of exposure and unmeasured risk factors including smoking, alcohol and physical activity. "Future studies might explore whether similar patterns are observed with other diasporic populations and famines," they write. "Findings emphasize the need for policymakers, health care professionals, and patients to consider the important early life influences that manifest decades later, contributing to the growing burden of T2D and hypertension worldwide."