Table 3

Characteristics of included studies investigating the association between exposure to a disaster during the perinatal and childhood periods and cardiometabolic outcomes across the life-course, by disaster type (n=24)

StudyStudy designCountryName of disasterYearSample sizePrimary exposure and comparatorAverage follow-upOutcomesPrimary results*
Human-made disaster with child/youth outcomes
 Trasande et al47Prospective cohortUSAWorld Trade Center attacks (9/11)2001402New York children and youth enrolled in the World Trade Center Health Registry (WTCHR) (birthdates: 11 Sept 1993–10 September 2001) compared with individuals born during the same time period who were ineligible for enrolment in the WTCHR2 yearsYouth outcomes:

  1. BMI (kg/m2)

  2. zBMI

  3. Trig (mg/dL)

  4. Chol (mg/dL)

  5. LDL (mg/dL)

  6. HDL (mg/dL)

Regression coefficient and 95% CI:

  1. BMI: −1.12 (−2.11 to –0.12)

  2. zBMI: −0.24 (−0.49 to 0.002)

  3. logTrig: 0.02 (−0.07 to 0.12)

  4. logChol: 0.02 (−0.02 to 0.06)

  5. log LDL: 0.06 (−0.001 to 0.12)

  6. logHDL: −0.04 (−0.10 to 0.03)

Human-made disaster with adult outcomes
 Bercovich et al40Cross-sectionalIsraelHolocaust1941–1945300European Jews born in 1940–1945 with exposure to the holocaust compared with European Jews during the same time period bornN/AAdult outcomes:

  1. Hypertension

  2. Diabetes

  3. Dyslipidaemia

  4. Any CVD

  1. Adjusted OR: 2.2, 95% CI: 1.2 to 3.8

  2. Adjusted OR: 2.2, 95% CI: 1.2 to 4.2

  3. Adjusted OR: 3.1, 95% CI: 1.7 to 5.7

  4. Adjusted OR: 2.6, 95% CI: 1.4 to 4.7

 de Rooij et al30CohortNetherlandsDutch famine1944–1945783Prenatal exposure to Dutch famine defined as people born between 7 January 1945 and 8 December 1945 compared with people born before 7 January 1945 or conceived after 8 December 194558 yearsMetabolic syndrome at age 58Metabolic syndrome OR: 1.2; 95% CI: 0.9 to 1.7
 Ekamper et al31CohortNetherlandsDutch famine1944–194541 096Male military conscripts born between Jan 1944 and 1946 and compared with military conscripts born before 1944 or after 194663 yearsAdult outcomes:
(1) Heart disease mortality, (2) cerebrovascular disease mortality, (3) diabetes mellitus mortality		HR:

  1. HR: 0.94; 95% CI: 0.77 to 1.15

  2. HR: 1.55; 95% CI: 0.95 to 2.51

  3. HR: 1.61; 95% CI: 0.91 to 2.86

 Huang et al37CohortChina1959–1961 Chinese famine1959–196135 025County-level famine intensity for women born during 1957–1962 compared with women born post-famine in 196332 yearsAdult outcomes at age 32: (1) BMI among rural sample, (2) BMI among urban sample, (3) hypertension among rural sample, (4) hypertension among urban sample

  1. Average effect=0.92, 95% CI: 0.32 to 1.51

  2. Average effect=0.03, 95% CI: −2.82 to 2.87

  3. Log odds=1.23, 95% CI: −0.38 to 2.84

  4. Log odds=0.37, 95% CI: −2.07 to 2.80

 Hult et al36CohortNigeriaBiafran famine1967–19701339Individuals exposed to famine during early childhood (born 1965–1967) or exposed to famine in fetal life and infancy (born 1968–Jan 1970) compared with people born between 1971 and 1973~40 yearsAdult outcomes at age ~40 years:

  1. Hypertension

  2. Diabetes

  3. Overweight (BMI >25 kg/m2)

  4. Obesity (BMI >30 kg/m2)

Adjusted OR (95% CI)

  1. Childhood exposure: 1.42 (0.63 to 3.13); fetal–infant exposure: 2.50 (1.19 to 5.26)

  2. Childhood exposure: 1.81 (0.64 to 5.15); fetal–infant exposure: 2.56 (0.92 to 7.17)

  3. Childhood exposure: 1.02 (0.77 to 1.34); fetal–infant exposure: 1.41 (1.03 to 1.93)

  4. Childhood exposure: 1.20 (0.87 to 1.67); fetal–infant exposure: 1.30 (0.92 to 1.85)

 Lumey et al32*CohortNetherlandsDutch famine1944–19451075Infants whose mothers were exposed to famine during or immediately preceding pregnancy (born 1 Feb 1945–31 March 1946) compared with individuals born in the same hospital before or after famine~56–62 yearsAdult outcomes at 56–62 years:
coronary artery disease		Early gestation HR: 1.26, 95% CI: 0.59 to 2.70
Late gestation HR: 1.31, 95% CI: 0.67 to 2.57
 Painter et al33CohortNetherlandsThe Dutch famine1944–1945975Infants who were born between January 1945 and December 1945 who were exposed to famine in utero compared with infants born before the famine (November 1943 and January 1945) and after the famine (December 1945 and February 1947)~50–58 yearsAdult outcomes at 50–58 years:
coronary artery disease		HR: 1.9, 95% CI: 1.0 to 3.8
 Ravelli et al34†CohortNetherlandsThe Dutch famine1944–1945741Infants exposed to famine during different periods of gestation (late, mid and early) whose maternal daily ration was <1000 kcal (born between January 1945 and December 1945) compared with those born not during the famine50 yearsObesity adult outcomes at 50 years stratified by sex:

  1. Weight (kg)

  2. BMI (kg/m2)

  3. Waist circumference (cm)

Mean difference (95% CI) between exposure during late or early gestation versus non-exposed:
Men:

  1. Late: 0.8 (−3.1 to 4.7); early: 1.5 (−3.5 to 6.6)

  2. Late: 0.4 (−3.5 to 4.5); early: 0.5 (−4.6 to 6.0)

  3. Late: 1.8 (−1.4 to 4.9); early: 1.8 (−2.4 to 6.0)


Women:

  1. Late: −1.8 (−6.1 to 2.5); early: 7.9 (2.5 to 13.2)

  2. Late: −2.1 (−7.0 to 3.1); early 7.4 (0.7 to 14.5)

  3. Late: −0.7 (−4.4 to 3.0); early: 5.7 (1.1 to 10.3)

 Roseboom et al29†CohortNetherlandsThe Dutch famine1944–19452414Infants who were exposed to famine in utero whose mother had a daily ration <1000 calories during any 13-week period of gestation compared with infants who were born before or conceived after the famine period (before November 1943 or after February 1947)~28 yearsAdult outcomes at 28 years;

  1. Plasma glucose (mmol/L)

  2. Plasma insulin (pmol/L)

  3. Total cholesterol (mmol/L)

  4. HDL (mmol/L)

  5. LDL (mmol/L)

  6. LDL/HDL cholesterol

  7. BMI (kg/m2)

  8. CHD

  9. Systolic BP (mm Hg)

  10. Diastolic BP (mm Hg)

Mean values of outcomes for late gestation and early gestation:

  1. Late: 6.3; early: 6.1

  2. Late: 200; early: 207

  3. Late: 5.83; early: 6.13

  4. Late: 5.83; early: 6.13

  5. Late: 1.32; early: 1.26*

  6. Late: 3.87; early: 3.26*

  7. Late: 26.7; early: 28.1

  8. Late: 2.5; early: 8.8*

  9. Late: 127.4; early: 123.4

  10. Late: 86.4; early: 84.8


*p<0.05
 Schreier et al41CohortFinlandWinter War and Continuation War1939–1940 (Winter War), 1941–1944 (Continuation War)13 039Individuals in utero who were exposed to bombings that occurred for 48 days between 1934 and 1944 compared with those who were not exposed in utero~60–70Adult outcomes:

  1. CHD

  2. Cerebrovascular disease

Results are shown graphically
Higher CHD survival rates among women 64+ years and among men aged 50–54 years exposed while in utero
 Stein et al35CohortNetherlandsThe Dutch famine1944–1945971Prenatal exposure to famine defined as the weeks post-last menstrual period that mother was exposed to an official ration of <900 kcal/week (gestation weeks: 1–10, 11–20, 21–30, or 31–delivery)59Adult outcomes:

  1. Systolic BP (mm Hg)

  2. Diastolic BP (mm Hg)

  3. Hypertension

Adjusted regression coefficients

  1. 1–10 weeks: 1.20 (95% CI: −3.28 to 5.69); 11–20 weeks: −1.19 (95% CI: −4.92 to 2,55); 21–30 weeks: 1.33 (95% CI: −2.24 to 4.90); 31–delivery: 2.02 (95% CI: −1.53 to 5.57)

  2. 1–10 weeks: 1.10 (95% CI: −1.36 to 3.57); 11–20 weeks: −1.26 (95% CI: −3.32 to 0.80); 21–30 weeks: 1.19 (95% CI: −0.78 to 3.15); 31–delivery: 0.71 (95% CI: −1.24 to 2.66)

  3. 1–10 weeks: 1.14 (95% CI: 0.62 to 2.11); 11–20 weeks: 0.98 (95% CI: 0.59 to 1.65); 21–30 weeks: 1.23 (95% CI: 0.74 to 1.05); 31–delivery: 1.42 (95% CI: 0.86 to 2.35)

Natural disaster with pregnancy outcomes
 Oni et al27Cross-sectionalUSAHurricane Katrina2005146Women who were pregnant during Hurricane Katrina or became pregnant immediately after hurricane compared with those who were not exposed to the hurricane; women who experienced prenatal stress caused by Hurricane Katrina compared with those who did not experience stress9 monthsPregnancy-related outcomes:

  1. Pregnancy-induced hypertension

  2. Gestational diabetes

  1. Hurricane exposure: adjusted OR: 1.22 (95% CI: 0.81 to 1.84); perceived stress: adjusted OR: 1.16 (95% CI: 1.05 to 1.30)

  2. Hurricane exposure: adjusted OR: 1.04 (95% CI: 0.69 to 1.57); perceived stress: adjusted OR: 1.13 (95% CI: 1.02 to 1.25)

 Xiao et al28Time-series/quasi-experimentalUSAHurricane Sandy2012Not reportedExposure to Hurricane Sandy lasting impacts defined as the following 12 months after Sandy (November 2012–October 2013) compared with the November–October in other years during November 2005–October 2014 among women who were pregnant12 monthsOutcomes in adults:

  1. Emergency department visits for gestational hypertension

  2. Emergency department visits for diabetes or abnormal glucose

  1. Increased at 7 months: 7.3% (95% CI: 1.0% to 13.9%)

  2. Increased at 8 months: 26.3% (95% CI: 3.9% to 53.6%)

*Results for 12 months reported graphically
Natural disaster with child/youth outcomes
 Cao-Lei et al26CohortCanadaQuebec ice storm199831Negative cognitive appraisal of the impact of the ice storm among pregnant women compared with neutral or positive appraisal13 yearsOutcomes among children at age 13 years:

  1. Central adiposity (waist to height ratio)

  2. BMI (kg/m2)

Mean (SD)

  1. Exposed: 20.86 (3.73); unexposed: 22.84 (5.19)

  2. Exposed: 0.43 (0.04); unexposed: 0.45 (0.06)

 Dancause et al23CohortCanadaQuebec ice storm1998111Higher objective PNMS scores compared with lower scores among women who were pregnant or conceived within 3 months of the storm5.5 yearsChildhood obesity at 5.5 years of ageOR: 1.37, 95% CI: 1.06 to 1.77
 Dancause et al24CohortCanadaQuebec ice storm199832Higher objective hardship compared with lower hardship scores reported among pregnant women exposed to the storm13.4 yearsChildhood insulin secretion at 13 years of ageInsulin secretion: adjusted linear regression standardised coefficient=0.52, p<0.01
 Dancause et al22CohortUSAIowa flood2008106Higher reported measures of objective hardship and subjective distress compared with lower scores among pregnant women during the floods2.5–4 yearsChildhood outcomes:

  1. Child BMI z-scores at age 2.5

  2. Child BMI z-scores at age 4

  3. Difference in BMI from age 2.5 to 4 years

  4. Child adiposity (skinfolds) at age 2.5 years

  5. Child adiposity (skinfolds) at age 4 years

  6. Difference in adiposity from age 2.5 to 4 years

Beta coefficient (p value)

  1. –0.07 (0.56)

  2. –0.22 (0.07)

  3. 0.11 (0.41)

  4. 0.00 (0.97)

  5. –0.06 (0.72)

  6. 0.03 (0.82)

 Goudet et al15CohortBangladesh1998 Bangladesh flood1998220Maternal malnutrition among mothers of infants and young children following flood exposure defined as underweight (BMI <18.5 kg/m2) compared with normal (BMI ≥18.5)12 monthsChild outcomes at 12–36 months of age:

  1. Underweight (weight for age z-score <−2)

  2. Stunted (height for age z-score <−2)

  3. Wasted (weight for height z-score <−2)

  1. Adjusted OR=3.509, 95% CI: 1.022 to 12.048)

  2. Adjusted OR: 4.447, 95% CI: 1.044 to 18.943

  3. Adjusted OR: 2.097, 95% CI: 0.507 to 8.671

 Kroska et al21Longitudinal studyUSAIowa flood2008103Levels of maternal stress among those exposed to Iowa floods2.5 yearsChildren outcomes at 2.5 years:
BMI (kg/m2)		Standardised coefficient: 0.2071 (p=0.0322)
 Liu et al25Longitudinal studyCanadaQuebec ice storm199852–111 at different time pointsLevels of maternal stress (objective hardship and subjective stress) among those exposed to Iowa floods5.5–15.5 yearsChildren outcomes at 5.5–15.5 years:

  1. BMI (kg/m2)

  2. Waist to height ratio

Correlation r (p value)
Age 8.5 years

  1. Objective hardship: 0.21 (0.05)

  2. Objective hardship: 0.23 (0.03)


Age 15.5 years

  1. Objective hardship: 0.34 (0.02)

  2. Objective hardship: 0.44 (<0.01)

Natural disaster with adult outcomes
 Mazumder et al38CohortUSA1918 influenza pandemic1918–1919101 068Infants who were born during the influenza pandemic (third and fourth quarter of 1918, and the first, second and third quarter of 1919) compared with those born in the last quarter of 1919~60–82 yearsAdult outcomes at 60–82 years:

  1. Diabetes

  2. Heart disease

Excess cases of diabetes/heart disease:

  1. 1918 Q4: 7.7% excess (95% CI: −10.6% to 25.9%); 1919 Q1: −5.2 (95% CI: −22.9 to 12.5); 1919 Q2: 36.7% excess (95% CI: 18.9% to 54.4%);

  2. 1918 Q4: 4.6% excess (95% CI: −4.3% to 13.5%); 1919 Q1: 10.9% excess (95% CI: 2.3% to 19.6%); 1919 Q2: 6.4% excess (95% CI: −2.2% to 15.1%)

 Myrskyla et al39‡CohortUSA1918 influenza pandemic1918–191981 571Infants who were born during the influenza pandemic (born during different quarters of 1917, 1918 and 1919) compared with those born in 1920–1924~63–95 yearsAdult outcomes at 63–95 years:
cardiovascular mortality		1918 Q1 HR: 1.05 (95% CI: 0.94 to 1.17); 1918 Q2 HR: 1.02 (95% CI: 0.91 to 1.14); 1918 Q3 HR: 0.99 (95% CI: 0.89 to 1.10); 1918 Q4 HR: 0.97 (95% CI: 0.87 to 1.09); 1919 Q1 HR 1.07 (95% CI: 0.96 to 1.19); 1919 Q2 HR: 1.06 (95% CI: 0.95 to 1.19)
 Sotomayor42Cohort/
natural experiment		Puerto RicoHurricanes San Felipe and San Cipiran1928 and 193211 990Those born during 1929 and 1933 were defined as exposed to the hurricanes compared with individuals born outside of these years between 1920 and 1940Not reported (average age=70 years)Outcomes at ~70 years of age:

  1. Diabetes

  2. Hypertension

  3. High cholesterol

  4. CVD

  5. AMI

  6. Coronary/angina

  7. Stroke

Linear regression estimates (p value)

  1. San Felipe: 5.94 (<0.01); San Ciprian: 5.43 (<0.01)

  2. San Felipe: 4.73 (<0.01); San Ciprian: 6.39 (<0.01)

  3. San Felipe: 8.85 (<0.01); San Ciprian: 5.28 (<0.01)

  4. San Felipe: −1.48; San Ciprian: 1.33

  5. San Felipe: 0.81; San Ciprian: 3.26 (<0.01)

  6. San Felipe: 0.40; San Ciprian: −0.60

  7. San Felipe: −0.25; San Ciprian: 0.58

  • *Results are numbered to correspond with the numbered outcomes in the outcomes column.

  • †Only presenting results for early and late gestation; results for mid-gestation are not included in summary table but can be found in studies.

  • ‡Not all results presented for different exposure groups.

  • AMI, acute myocardial infarction; BMI, body mass index; BP, blood pressure; CHD, coronary heart disease; Chol, cholesterol; CVD, cardiovascular disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein; N/A, not available; PNMS, prenatal maternal stress; Q1–Q4, quarter; Trig, triglycerides.