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Early Life Exposure to the Chinese Famine of 1959-61 and Type 2 Diabetes in Adulthood: A Systematic Review and Meta-Analysis
29 Pages Posted: 21 Apr 2022
More...Abstract
Background: There is a fast-growing literature suggesting that the Chinese famine of 1959–61 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 and demonstrate how they bias study results. We formulate recommendations to improve the quality of future studies.
Methods: We searched English and Chinese databases, including PubMed, EMBASE, Web of Science, Wanfang Data, and the Chinese National Knowledge Infrastructure, for studies that examined the relationship between prenatal exposure to the Chinese famine and adult T2D from inception to February 8, 2022. From the included studies, 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: postfamine births, combined pre- and postfamine births, and prefamine births. We used meta-regressions and subgroup analyses to examine the impact 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.
Findings: Twenty-three studies met our inclusion criteria. Sample sizes ranged from less than 300 to more than 360,000 participants. All studies defined the famine exposure based on participants' dates of birth, and 18 studies compared famine births and postfamine births to estimate famine effects on T2D. Famine and postfamine births had an age difference of three years or more in all studies. 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). Meta-regressions further showed that famine effect estimates were predominantly driven by the age difference between famine births and controls. Other problems included poorly assessed famine intensity, unsuitable study settings for famine research, and poor confounding adjustment.
Interpretation: 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.
Funding Information: None.
Declaration of Interests: We declare no competing interests.
Keywords: Chinese famine, diabetes, age difference, methodological problems
Suggested Citation: Suggested Citation