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IntroductionChild undernutrition and later-life non-communicable diseases (NCDs) are major global health issues. Existing literature suggests that undernutrition/famine exposure in childhood has immediate and long-term adverse health consequences. However, many existing studies have theoretical and methodological limitations. To add to the literature and overcome some of these limitations, we adopted a life course perspective and used more robust methods to investigate the association between exposure to the 1959-1961 Chinese famine and later-life NCDs and if this association depends on: life stage (age) at exposure, severity of exposure, and sex.MethodsSecondary data analysis of the China Health and Retirement Longitudinal Study (2011-2018,Nparticipants=11,094). We measured famine exposure and severity using self-reported experience, life stages using age at exposure, and health using the number of NCDs. We performed Poisson growth curve models.ResultsFirst, compared with unexposed participants, those exposed before age of 18 had a higher risk of later-life NCDs, particularly if exposed in-utero (IRR=1.90, 95% CI [1.70, 2.12],p< .001) and in the “first 1,000 days” of life (IRR=1.86, 95% CI [1.73, 2.00],p< .001; for 0-6 months group, IRR=1.95, 95% CI [1.67, 2.29],p< .001). Second, the famine effects among participants moderately and severely exposed were similar (IRR = 1.18, 95% CI [1.09, 1.28],p< .001 and IRR = 1.24, 95% CI [1.17, 1.32],p< .001). Third, the famine effects did not differ between females and males (IRR = 0.98, 95% CI [0.90, 1.07],p= .703).ConclusionIn the life course of an individual, in-utero and the “first 1,000 days” are a particularly sensitive time period with marked long-term implications for NCDs if undernutrition/famine are experienced in this period. However, this window remains open until young adulthood. This highlights the need to invest more in both preventing and treating child/adolescent undernutrition to tackle the problem of later-life NCDs.KEY MESSAGESWhat is already known on this topic?▸Undernutrition in childhood and non-communicable diseases (NCDs) in later life are major global public health problems.▸Links between early-life undernutrition and later-life NCDs are well documented but mechanisms are not, leaving evidence gaps for prevention and treatment strategies.▸Many previous studies have theoretical limitations in that they lack a life course perspective and methodological limitations in how they account for age and famine exposure/severity.What this study adds?▸Adopting a life course perspective and using more robust methods to adjust for age and to measure famine exposure/severity more directly, we show that famine exposure in childhood and adolescence is associated with NCDs in later life (age 50+).▸Early life (in-utero and infancy, especially the first six months of life) is a particularly sensitive time period associated with high future risk. However, the window of sensitivity remains open until young adulthood.▸Associations between famine exposure and NCDs in later life do not depend on severity of famine exposure nor on sex.How this study might affect research, practice or policy?▸Preventing undernutrition/famine in children and adolescents should be seen as an important long-term investment in health rather than just a short-term cost.▸The current focus of global nutrition programmes on the in-utero and the “first 1,000 days” of life is important, but older children and adolescents also matter and should be included in undernutrition prevention/treatment programmes, given evidence for continuing risks.▸Our observation that infants aged 0-6 months are particularly vulnerable to famine exposure further justifies WHO’s current focus on this age group in upcoming wasting guidelines.