786 Bister L, et al. J Epidemiol Community Health 2022;76:786–791. doi:10.1136/jech-2021-218637
Original research
Early-­life exposure to economic stress and metabolic
risks in young adulthood: the children of the
reunification in East Germany
Lara Bister  ‍ ‍,1
Fanny Janssen,1,2
Tobias Vogt1,3
To cite: Bister L, Janssen F,
Vogt T. J Epidemiol
Community Health
2022;76:786–791.
	► Additional supplemental
material is published online
only.To view, please visit
the journal online (http://​dx.​
doi.​org/​10.​1136/​jech-​2021-​
218637).
1
Population Research Centre,
University of Groningen,
Groningen,The Netherlands
2
Netherlands Interdisciplinary
Demographic Institute – KNAW
/ University of Groningen,The
Hague,The Netherlands
3
Prasanna School of Public
Health, Manipal Academy for
Higher Education, Manipal, India
Correspondence to
Lara Bister, Population Research
Centre, University of Groningen,
Groningen,The Netherlands;
​l.​bister@​rug.​nl
Received 3 January 2022
Accepted 12 June 2022
Published Online First
23 June 2022
© Author(s) (or their
employer(s)) 2022. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
ABSTRACT
Background  Research on the long-­term health
consequences of early-­life exposure to economic crises
is scarce.We examine for the first time the long-­term
effects of early-­life exposure to an economic crisis
on metabolic health risks.We study objective health
measures, and exploit the quasi-­experimental situation of
the postreunification economic crisis in East Germany.
Methods  Data were drawn from two waves of the
longitudinal German Health Interview and Examination
Survey for Children and Adolescents (2003–2006,
2014–2017).We compared 392 East Germans who
were exposed to the economic crisis in utero and at
ages 0–5 with 1123 of their West German counterparts
using propensity score matching on individual and family
characteristics.We assessed blood pressure, cholesterol,
blood fat and body mass index (BMI); both combined as
above-­average metabolic health risks and individually at
ages 19–30.
Results  Early-­life exposure to the economic crisis
significantly increased the number of above-­average
metabolic health risks in young adulthood by 0.1482
(95% CI 0.0169 to 0.2796), which was 5.8% higher
compared with no exposure.Among individuals exposed
in utero, only females showed significant effects. Early-­
life exposure to the economic crisis was associated with
increased systolic (0.9969, 95% CI −0.2806 to 2.2743)
and diastolic blood pressure (0.6786, 95% CI −0.0802
to 1.4373), and with increased BMI (0.0245, 95% CI
−0.6516 to 0.7001).
Conclusion  The increased metabolic health risks found
for women exposed to the postreunification economic
crisis in-­utero are likely attributable to increased
economic stress.While the observed differences are
small, they may foreshadow the emergence of greater
health disparities in older age.
INTRODUCTION
Economic crises pose a serious threat to population
health. Children are particularly sensitive to
extreme economic stress, which can occur during
an economic crisis.1
Previous research has unambiguously
shown that in utero and childhood exposure
to chronic stress may trigger metabolic health
responses,2
and that economic stress in particular
can have negative short-­term health effects.3–6
Moreover, there is evidence that early-­life exposure
to economic stress is associated with increased
metabolic health risks in late adulthood7
and
cardiovascular mortality later in life.8
This link can
be explained using the critical period model within
the life course approach, which hypothesises that
development in the early and vulnerable life stages
(eg, in utero or childhood) is sensitive to external
stressors, and thus that exposure to such stressors
can lead to long-­term negative health outcomes.9
Research on the early adult health outcomes
of individuals who experienced economic stress
early in life is scarce. Metabolic health in particular
is a health indicator that can be used to
measure the long-­term consequences of early-­life
exposure to economic stress. Negative metabolic
health outcomes may result from increased exposure
to financial and general distress10 11
and from
WHAT IS ALREADY KNOWN ON THIS TOPIC
	⇒ Previous research has reported that exposure
to economic stress has significant adverse
effects on children and newborns. Moreover,
while existing studies have found that
economic crises can have short-­term adverse
effects on the metabolic health of children
and adolescents, most of this research was
focused solely on behavioural and subjective
health measures.While early-­life exposure to
economic stress has been found to affect later-­
life cardiovascular mortality, adult metabolic
health in the context of early-­life exposure to
an economic crisis remains understudied.
WHAT THIS STUDY ADDS
	⇒ Exploiting the quasi-­experimental situation
of the economic crisis in postreunification
East Germany, our findings reveal significant
increases in metabolic health risks for young
adults who were exposed to the economic crisis
early in life, especially for females.We found
that the blood pressure and body mass index of
young adults were particularly affected, which
could be linked to the long-­term metabolic
health consequences of early-­life exposure to
economic stress. Furthermore, we observed
that in utero exposure to the economic crisis
led to increased metabolic health risks among
young adult females in particular, which might
be attributable to females having a higher
sensitivity to economic stress than males.The
impact of early-­life exposure to the economic
crisis on metabolic health risks was up to
five times larger than that of other adverse
childhood experiences, such as parental
separation.
Protectedbycopyright.
onDecember11,2024atMasarykuniversityinBrno.http://jech.bmj.com/JEpidemiolCommunityHealth:firstpublishedas10.1136/jech-2021-218637on23June2022.Downloadedfrom
787Bister L, et al. J Epidemiol Community Health 2022;76:786–791. doi:10.1136/jech-2021-218637
Original research
subsequent physiological dysregulation,12
which has also been
linked to long-­term cardiovascular health.13
Thus, studying these
outcomes can enable us to capture the health effects of economic
stress in a comprehensive way.
The few previous studies that have examined the short-­term
adverse metabolic health consequences of economic crises for
children and adolescents14–16
identified significant adverse
effects, but focused solely on subjective health measures. These
authors looked at the short-­term health responses of individuals
aged 0–17, 3–10 years after the onset of the global financial crisis
of 2008. The studies found, for example, a 39% increase in the
number of families experiencing food insecurity in the USA14
;
higher levels of fast food consumption and of average weight
gain in Portugal15
; and an 8.5% increase in obesity prevalence, a
2.1% increase in junk food consumption, and a 3.61% decrease
in physical activity in Catalonia, Spain.16
These adverse health
effects may be attributable to family economic stress arising from
actual or perceived threats of job loss, reduced income or material
hardship that occurred during the economic crisis.1 17–20
Thus, it is clear that the long-­term metabolic health consequences
of early-­life exposure to economic stress are not yet well
understood. In addition to being academically relevant, investigating
the relationship between exposure to economic stress
in utero or in childhood and adult metabolic health responses
can help policy-­makers develop health interventions that protect
people who have been exposed to economic crises as minors
from experiencing long-­term negative health consequences.2
Our objective is to study the metabolic health effects of early-­
life exposure to an economic crisis in young adulthood.
We examine for the first time the long-­term effects of early-­
life exposure to an economic crisis on metabolic health risks in
early adulthood. For our analysis, we use the unique context and
quasi-­experimental setting of the postreunification economic
crisis in East Germany. Starting in 1990, the East German
economy underwent a severe economic crisis as the region transitioned
from having full employment before German reunification
to suffering from extremely high unemployment and
economic decline after reunification. By contrast, economic
conditions remained relatively stable in West Germany over this
period21 22
(see online supplemental chapter S1.1). We study
objective measures of metabolic health while exploiting the
longitudinal design of the German Health Interview and Examination
Survey for Children and Adolescents (KiGGS).
METHODS
We exploited the quasi-­experimental setting of the severe
economic crisis in postreunification East Germany21 22
using
retrospective observational data from the German Health
Interview and Examination Survey for Children and Adolescents
(KiGGS).23
We obtained baseline information and information
on the demographic characteristics of these children and their
parents from the first KiGGS wave (collected 2003–2006), and
information on their health outcomes in young adulthood from
the third KiGGS wave (collected 2014–2017). We obtained a
total sample of 1515 individuals (see online supplemental figure
S1 for sample selection), including 392 East Germans (26%) and
1123 West Germans (74%) who were born between 1985 and
1994, and were thus exposed to the economic crisis early in life
(in utero or at ages 0–5).
Our outcome measure was metabolic health measured at ages
19–30. We used four cardiometabolic risk factors: (1) blood pressure
(systole-­diastole ratio, mm Hg), (2) body mass index (BMI)
in kg/m2
, (3) cholesterol levels (high-­density lipoprotein (HDL)
in blood, mg/dL) and (4) body fat levels (triglyceride in blood,
mg/dL).24
We analysed the measures individually and combined
as a composite measure indicating the number of above-­average
metabolic health risks for each metabolic health measure, that is,
a count variable ranging from zero (no above-­average metabolic
risks) to four (four above-­average metabolic risks).
The exposure measure was early-­life exposure to the postreunification
economic crisis in East Germany, which was based on
whether each respondent’s place of residence in the first KiGGS
wave (2003–2006) was in East Germany instead of in West
Germany. Because East and West Berlin were not differentiated
in the data, we excluded Berlin. We obtained the average treatment
effect (ATE) of exposure to the postreunification economic
crisis in East Germany by applying propensity score matching,
which reduced bias from confounding by ensuring that the
exposed sample and the unexposed sample were balanced in
terms of their characteristics25
(online supplemental table S4).
We matched the East German (treatment group) with the West
German sample (control group) using the following uncorrelated
variables as confounders (online supplemental table
S5): age at health examination (continuous), gender, birth year
(continuous), birth weight (continuous), preterm birth (dummy),
mother’s age at childbirth (continuous) and parental education
(continuous). See online supplemental tables S1-­S3 for the variable
descriptions and the descriptive statistics for outcome, treatment
and control measures.
For a more detailed description, see online supplemental
chapter S1.
RESULTS
The overall number of above-­average metabolic risks was higher
for the exposed group (=East Germans), with an average of
2.70, than for the unexposed group (=West Germans), with
an average of 2.57. This difference was statistically significant
(p<0.05) (table 1). There was no statistically significant difference
in the individual metabolic health measures of the exposed
group and the unexposed group. However, the systolic and
diastolic blood pressure was higher for the exposed group than
for the unexposed group (123.65/73.45 mm Hg vs 122.66/72.85
mm Hg). The metabolic health outcomes for males were also not
significantly different. For females, however, we found significantly
higher average metabolic health risks in the composite
measure (2.49 vs 2.24, p<0.05) and the systolic and diastolic
blood pressure (119.77/72.96 mm Hg vs 117.74/71.70 mm Hg,
p<0.05).
The effect on the composite metabolic health measure for the
exposed group was, at 0.1482 (p<0.05) (table 2), 5.8% higher
than the number of above-­average metabolic health risks for the
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE
AND/OR POLICY
	⇒ Our findings suggest that individuals exposed to economic
crisis early in their lives face a higher risk of physical
dysregulation and cardiovascular health hazards later in
life.This signals a possible delayed burden on the health
system due to increased treatment requirements in the
future. Subsequently, policy-­makers should adopt measures
to alleviate the economic stress of families during economic
crises, and to promote compensating health behaviours
among the affected individuals to help counteract the
adverse long-­term metabolic health consequences of early-­
life exposure to economic crises.
Protectedbycopyright.
onDecember11,2024atMasarykuniversityinBrno.http://jech.bmj.com/JEpidemiolCommunityHealth:firstpublishedas10.1136/jech-2021-218637on23June2022.Downloadedfrom
788 Bister L, et al. J Epidemiol Community Health 2022;76:786–791. doi:10.1136/jech-2021-218637
Original research
unexposed group. While the effect on the composite measure
was not statistically significant in males, it was in females, at
0.236 (p<0.05). For the individual metabolic health measures,
the estimates of systolic and diastolic blood pressure and BMI
were increased in the total exposed sample, although only the
effect for diastolic blood pressure was statistically significant.
Conversely, the positive HDL and negative triglyceride estimates
indicate that the control group were in worse health, although
these values were not statistically significant. The single estimates
show no significant effect in males. However, systolic blood
pressure was, at 2.136 mmHg (p<0.05), significantly higher in
the exposed females than in the unexposed females. While the
outcomes for the remaining metabolic health measures seem to
be worse in the exposed females than in the unexposed females,
the differences were not significant.
Figure 1 plots the ATE of early-­life exposure to economic
stress on metabolic health risks (composite measure) in young
adulthood, assessed separately for the cohorts born between
1986 and 1994 and stratified by gender. We found no effect
among males (left panel). Among females (right panel), we
observed statistically significant effects of 0.821 for the 1992
birth cohort (increase of 39.2%, p<0.01) and of 0.622 for the
1993 birth cohort (28.7%, p<0.05) on the number of above-­
average metabolic health risks for the exposed group compared
with the unexposed group. These birth cohorts were exposed to
the economic crisis in utero. We found no effect for the exposed
members of the earlier birth cohorts.
CONCLUSION
Summary of results
Early-­life exposure to the economic crisis significantly increased
the number of above-­average metabolic health risks in young
adulthood by 0.1482 (95% CI 0.0169 to 0.2796), which was
5.8% higher compared with no exposure. Significant effects
were found only for females exposed in utero. Early-­life exposure
to the economic crisis was associated with increased systolic
(0.9969, 95% CI −0.2806 to 2.2743) and diastolic blood pressure
(0.6786, 95% CI −0.0802 to 1.4373) and with increased
BMI (0.0245, 95% CI: −0.6516 to 0.7001).
Evaluation of data and methods
Our study has some data-­related limitations.
First, because the KiGGS only provided information on the
region of residence—that is, our exposure measure—for the first
wave (2003–2006), we had to consider the possibility that our
results were affected by unobserved migration between German
reunification in 1990 and the first KiGGS wave. However,
our sensitivity analysis, in which we considered the impact of
East-­West migration among a subsample for whom the pre-­
reunification residence was known, showed that migration did
not affect our results (online supplemental table S7).
Second, because the KiGGS did not provide information
on the respondents’ exposure to economic stress, but
only allowed for a linkage with contextual information on
the postreunification economic crisis through geographical
Table 1  Comparison of the young adult (ages 19–30) mean metabolic health outcomes between the exposed (East German) and the unexposed
(West German) matched samples, 2014–2017 (N=1515)
Metabolic health outcome
Total Males (n=791) Females (n=724)
Exposed† (n=389) Unexposed‡ (n=1121) Exposed† (n=212) Unexposed‡ (n=564) Exposed† (n=171) Unexposed‡ (n=543)
Composite measure (0–4) 2.70* 2.57* 2.88 2.89 2.49* 2.24*
Systolic blood pressure§ 123.65 122.67 126.69 127.36 119.77* 117.74*
Diastolic blood pressure§ 73.47 72.85 73.97 74.03 72.96* 71.70*
Body mass index¶ 24.25 24.39 24.32 24.91 24.07 23.88
High-­density lipoprotein**†† 26.51 26.40 23.73 23.33 30.01 29.57
Triglyceride** 24.09 24.20 25.18 26.54 22.73 21.87
Bold values indicate significant coefficients.
Significance levels (T-­test results): ***p<0.001, **p<0.01, *p<0.05.
Interpretation of measures: †matched East German sample, †matched West Germany sample,§mmHg; ¶kg/square metre; **mg/dL in blood; ††lower high-­density lipoprotein means
higher cholesterol levels
Table 2  Effect of early-­life exposure to the postreunification economic crisis in East Germany (comparing East and West German samples) on
combined and individual metabolic health outcomes at young adulthood (ages 19–30), 2014–2017 (N=1515)
Metabolic health outcome
Total (N=1515) Males (N=791) Females (N=724)
ATE 95% Conf. Int. ATE 95% Conf. Int. ATE 95% Conf. Int.
Composite measure (0–4) 0.148* 0.026 to 0.270 0.004 −0.143 to 0.151 0.236* 0.077 to 0.395
Systolic blood pressure† 0.997 −0.229 to 2.223 −0.976 −2.702 to 0.751 2.136** 0.397 to 3.875
Diastolic blood pressure† 0.679* 0.004 to 1.400 −0.386 −1.196 to 0.424 1.331 −0.357 to 3.019
Body mass index‡ 0.024 −0.637 to 0.685 −0.679 −1.423 to 0.066 0.377 −0.781 to 1.535
High-­density lipoprotein§¶ 0.396 −0.470 to 1.263 0.538 −0.255 to 1.330 0.706 −0.468 to 1.879
Triglyceride§ −0.306 −2.216 to 1.605 −1.155 −4.754 to 2.445 0.820 −1.141 to 2.781
ATE which we obtained from propensity score matching; see online supplemental table S6 for calculations of the propensity score.
Bold values indicate significant coefficients.
Significance levels: ***p<0.001, **p<0.01, *p<0.05.
Interpretation of measures: †mmHg; ‡kg/square metre; §mg/dL in blood; ¶lower high-­density lipoprotein means higher cholesterol levels.
ATE, average treatment effect.
Protectedbycopyright.
onDecember11,2024atMasarykuniversityinBrno.http://jech.bmj.com/JEpidemiolCommunityHealth:firstpublishedas10.1136/jech-2021-218637on23June2022.Downloadedfrom
789Bister L, et al. J Epidemiol Community Health 2022;76:786–791. doi:10.1136/jech-2021-218637
Original research
information based on the children’s residential location, we
must acknowledge the possible influence of unobservable
confounders. Previous research has emphasised that during
an economic crisis, child health is affected by parental unemployment
and financial hardship, and by the family’s socioeconomic
gradient.15 16
However, information regarding the
parents’ employment status, the household’s financial situation
or the family’s socioeconomic status during the postreunification
economic crisis was not available in the data.
We consider it likely that growing up in a socioeconomically
disadvantaged family characterised by parental unemployment
and financial hardship amplified the observed adverse metabolic
health effects for those affected. We concede that having
family-­level information on exposure to the economic crisis
would help to complete the overall picture,26
and allow us to
draw inferences regarding the socioeconomic stratification of
the health consequences27
of the macrolevel economic shock
in postreunification East Germany. Thus, future research
on the long-­term metabolic health effects of exposure to an
economic crisis should provide a closer examination of the
role of family-­level socioeconomic differences.
Third, although our outcome measures are objective measures
and relevant predictors of metabolic health, two key indicators
for the metabolic syndrome, namely abdominal obesity and
hyperglycaemic,13
are not available in the KiGGS. Additionally,
clinical benchmarks for metabolic syndrome risk cut-­off points
for the available metabolic health measures that were exclusively
adapted to the young age of our study population13 28
are
limited in the literature. For that reason, we did not use clinically
relevant thresholds for the composite measure of the combined
metabolic risk score. Instead, we relied on a sample-­based operationalisation
of the thresholds for increased metabolic risks, in
line with previous studies on metabolic health in comparably
young study populations.29
Discussion of results
Our finding that individuals exposed to the postreunification
economic crisis in East Germany had a higher number of above-­
average metabolic health risks in young adulthood can very likely
be linked to their experiences of economic stress in early life,
which may have negatively affected their long-­term metabolic
health.8 10
Our observation that the blood pressure and the BMI
of these young adults were particularly affected by exposure to
the crisis can be explained by research showing that these health
indicators are especially sensitive to stress.30 31
Moreover, our finding that these effects were only significant
for females is in line with previous research that detected
gender differences in physiological regulation in response to
increased distress.32 33
External stressors in particular often lead
to hormonal and physical dysregulation in women,33
and thus,
can also have an impact on their metabolic health.32
Our observation
that the differences in the metabolic health of females
were already evident in young adulthood reflects the severity of
the economic crisis.
Particularly for those East German cohorts who were exposed
to the economic crisis in utero—that is, the birth cohorts of
1992 and 1993—our results show significantly increased above-­
average metabolic health risks among females. These findings are
in line with the critical period model,9
as well as with previous
research showing that experiences in the early years of life can
have long-­term effects on health, including on metabolism.34
They also provide support for the fetal stress hypothesis, which
argues that external stressors in the womb have long-­term effects
on development and health.35–37
Thus, our findings indicate that
the postreunification economic crisis in East Germany likely
exposed unborn children to extreme in utero stress resulting
from their mothers’ economic distress. Why no significant
effects were found for East Germans who were exposed to the
crisis later in childhood is unclear. Although the negative impact
of in utero exposure to economic stress is well known,8 35
studies
that compare the effects of economic stress on children who
were exposed at different ages are rare. Future research should
investigate possible differences by age in the effects of exposure
to economic stress and seek to disentangle the corresponding
mechanisms.
Socioeconomic factors may play a crucial role in explaining
the adverse effects on metabolic health of early-­life exposure
to economic crises, as being socioeconomically disadvantaged
early in life has been found to negatively affect metabolic
health outcomes in adulthood.27
Experiencing elevated levels
of economic stress during an economic crisis may exacerbate
this effect and drive negative health selection. Research has
clearly shown that children from socioeconomically disadvantaged
backgrounds are particularly likely to suffer negative
health consequences during economic crises.16
While our study
cannot provide insights into socioeconomic selection into experiencing
negative metabolic health consequences due to early-­
life exposure to economic crises (see 4.2 Evaluation of data and
methods), we acknowledge the relevance of these factors for
individual metabolic health.
Alongside the explanatory mechanisms, it is important to
discuss the magnitude of the observed effect sizes. In general,
the differences we found in the metabolic health outcomes of
the exposed and the unexposed groups were rather small. This
is partially because we only observed effects for females and for
individuals exposed to the economic crisis in utero. We, thus,
acknowledge that gender differences likely drove the observed
overall effect of early-­life exposure to the economic crisis on
Figure 1  Effect of early-­life exposure to the postreunification
economic crisis in East Germany (comparing East and West German
samples) on above-­average metabolic health risks in young adulthood
(composite measure), individually estimated for the birth years
1986–1994 and stratified by gender, 2014–2017 (n (males) = 791,
n (females) = 724). Note: Effect size of above zero indicates higher
average metabolic risk factors for East Germans.The 1985 birth cohort
was omitted due to the small sample size (n=7);ATE obtained from
propensity score matching (see online supplemental table S4-­S6 for
propensity score matching procedure, balancing test statistics and
calculations).The postreunification economic crisis began in East
Germany after the fall of the Berlin Wall in November 1989.ATE,
average treatment effect.
Protectedbycopyright.
onDecember11,2024atMasarykuniversityinBrno.http://jech.bmj.com/JEpidemiolCommunityHealth:firstpublishedas10.1136/jech-2021-218637on23June2022.Downloadedfrom
790 Bister L, et al. J Epidemiol Community Health 2022;76:786–791. doi:10.1136/jech-2021-218637
Original research
metabolic risks in young adulthood. In addition, socioeconomic
gains over the early life course may have counteracted
the adverse effects of the economic crisis on the exposed group.
The rapid convergence of living standards, educational levels
and health policies in reunified Germany might have offset some
of the adversity experienced by children who were exposed
to the economic crisis in East Germany.38 39
Moreover, health
behaviours at young adult ages, such as physical activity, smoking
and alcohol consumption, might have influenced the effects on
metabolic health of early-­life exposure to the economic crisis by
either reinforcing or counteracting the negative effects through
unhealthy or healthy behaviours.40
However, given that the
scarce existing research on East-­West German differences in
health behaviour has found no significant differences between
the cohorts exposed to the postreunification economic crisis,41 42
we cannot determine whether health behaviour played a role.
To better understand and contextualise the effect sizes,
we conducted an additional analysis using the experience of
parental separation during childhood as a treatment. We chose
this comparative treatment because previous studies identified
parental separation as a significant stressor for children, and
emphasised its association with long-­term adverse metabolic
health effects.43
The additional analyses (online supplemental
table S8) showed that the effect of early-­life exposure to the
postreunification economic crisis in East Germany on the metabolic
health risks in young adulthood was three times larger than
that of parental separation during childhood. For females, the
effect was almost five times larger. These findings again illustrate
the severity of the postreunification economic crisis in East
Germany, and the subsequent consequences for the metabolic
health of individuals who were exposed to the crisis early in life.
Additionally, as we observed the differences in metabolic
health in young adulthood, it is possible that the exposed population
will develop more serious health consequences over time,
as previous research has shown that the prevalence of metabolic
syndrome44
and cardiovascular mortality8
increases with age.
Conclusion
Early-­life exposure to economic stress during the postreunification
economic crisis in East Germany led to increased metabolic
health risks for young adults, although only for women. In
particular, BMI and blood pressure were higher for the exposed
females. As BMI and blood pressure are common stress markers,
these findings can be attributed to stress responses to the
economic crisis. Moreover, these results emphasise the importance
of taking gender differences in responses fetal stress into
account when considering the long-­term health consequences of
early-­life exposure to economic crises.
Although the differences in the metabolic health outcomes we
detected were small—possibly due to the compensating effects of
later-­life improvements in the socioeconomic status of the East
Germans in our sample—the effects were certainly not negligible
(compared with, eg, the effects of parental separation). Our findings
could well signal that the exposed individuals face a higher
risk of physical dysregulation and cardiovascular health hazards
later in life. This could result in a very large but delayed burden
on the health system due to increased treatment requirements.
We recommend that policy-­makers in East Germany
adopt measures to alleviate the economic stress of families
during economic crises, and to promote compensating health
behaviours among the birth cohorts affected by the postreunification
economic crisis to help counteract the adverse long-­term
metabolic health consequences of exposure to this crisis.
Twitter Lara Bister @LaraBister
Acknowledgements  The authors would like to thank the fellow students at the
International Max Planck Research School for Population, Health and Data Science
(IMPRS-­PHDS), the staff of the Max Planck Institute for Demographic Research, and
in particular Dr. Peter Eibich for their feedback and guidance in developing this work.
Contributors  LB: guarantor, conceptualisation, methodology, software, formal
analysis, investigation, validation, data curation, writing—original draft, writing—
review and editing, visualisation, project administration. FJ: conceptualisation,
investigation, writing—review and editing, supervision.TV: conceptualisation,
investigation, writing—review and editing, supervision, project administration.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not applicable.
Ethics approval  We used secondary data from the German Health Interview
and Examination Survey for Children and Adolescents (KiGGS) by the Robert-­Koch
Institute (RKI) in Germany. Research ethics approval was therefore carried out by the
RKI.All studies of the RKI are subject to strict compliance with the data protection
regulations of the EU Basic Data Protection Regulation (DSGVO) and Federal Data
Protection Act (BDSG).The Ethics Commission of the Charité Universitätsmedizin
Berlin has reviewed the KiGGS basic survey (No. 101/2000) as well as KiGGS wave
1 (No. EA2/058/09); and the Ethics Commission of the Medizinische Hochschule
Hannover has reviewed ethical aspects and approved KiGGS wave 2 (No. 2275–
2014). Participation in the studies was voluntary. Participants or their guardians
were informed about the aims and contents of the studies and about data protection
measures, and gave their written consent for participation.
Provenance and peer review  Not commissioned; externally peer reviewed.
Data availability statement  Data may be obtained from a third party and are
not publicly available.
Supplemental material  This content has been supplied by the author(s). It
has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have
been peer-­reviewed.Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content.Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
ORCID iD
Lara Bister http://orcid.org/0000-0001-5915-757X
REFERENCES
	 1	 Rajmil L, Fernandez de Sanmamed M-­J, Choonara I, et al. Impact of the 2008
economic and financial crisis on child health: a systematic review. Int J Environ Res
Public Health 2014;11:6528–46.
	 2	 Pervanidou P, Chrousos GP. Metabolic consequences of stress during childhood and
adolescence. Metabolism 2012;61:611–9.
	 3	 Kyriopoulos I, Nikoloski Z, Mossialos E. Does economic recession impact newborn
health? Evidence from Greece. Soc Sci Med 2019;237:112451.
	 4	 Olafsson A. Household financial distress and initial endowments: evidence from the
2008 financial crisis: household financial distress and initial endowments. Health Econ
2016;25:43–56.
	 5	 Nikolova M, Nikolaev BN. Family matters: the effects of parental unemployment in
early childhood and adolescence on subjective well-­being later in life. J Econ Behav
Organ 2018.
	 6	 Spencer N,Thanh TM, Louise S. Low income/socio-­economic status in early childhood
and physical health in later childhood/adolescence: a systematic review. Matern Child
Health J 2013;17:424–31.
	 7	 Duque V, Schmitz L. The influence of early-­life economic shocks on aging outcomes:
evidence from the U.S. great depression, report No.: 3985570. Rochester, NY: Social
Science Research Network, 2021. https://papers.ssrn.com/abstract=3985570
	 8	 van den Berg GJ, Doblhammer-­Reiter G, Christensen K. Being born under adverse
economic conditions leads to a higher cardiovascular mortality rate later in life:
evidence based on individuals born at different stages of the business cycle.
Demography 2011;48:507–30.
	 9	 Kuh D, Richards M, Cooper R. Life course epidemiology, ageing research, and
maturing cohort studies: a dynamic combination for understanding healthy ageing. In:
Kuh D, Cooper R, Hardy R, eds. Life Course Approach Healthy Ageing [Internet. Oxford
University Press, 2013: 3–15. http://www.oxfordscholarship.com/view/10.1093/​
acprof:oso/9780199656516.001.0001/acprof-9780199656516-chapter-1. (cited
2020 Feb 4).
Protectedbycopyright.
onDecember11,2024atMasarykuniversityinBrno.http://jech.bmj.com/JEpidemiolCommunityHealth:firstpublishedas10.1136/jech-2021-218637on23June2022.Downloadedfrom
791Bister L, et al. J Epidemiol Community Health 2022;76:786–791. doi:10.1136/jech-2021-218637
Original research
	10	 Alastalo H, Räikkönen K, Pesonen A-­K, et al. Early life stress and blood pressure levels
in late adulthood. J Hum Hypertens 2013;27:90–4.
	11	 Slopen N, Loucks EB,Appleton AA, et al. Early origins of inflammation: an
examination of prenatal and childhood social adversity in a prospective cohort study.
Psychoneuroendocrinology 2015;51:403–13.
	12	 Glei DA, Goldman N, Chuang Y-­L, et al. Do chronic stressors lead to physiological
dysregulation? testing the theory of allostatic load. Psychosom Med 2007;69:769–76.
	13	 Eckel RH, Grundy SM, Zimmet PZ.The metabolic syndrome. The Lancet
2005;365:1415–28.
	14	 Bruening M, MacLehose R, Loth K, et al. Feeding a family in a recession: food
insecurity among Minnesota parents. Am J Public Health 2012;102:520–6.
	15	 Rodrigues D, Carmo A, Gama A, et al.The great recession weighted on Portuguese
children: a structural equation modeling approach considering eating patterns. Am J
Hum Biol []. 2022;34:e23692.
	16	 Rajmil L, Medina-­Bustos A, Fernández de Sanmamed M-­J, et al. Impact of the
economic crisis on children’s health in Catalonia: a before-­after approach. BMJ Open
2013;3:e003286.
	17	 Friedline T, Chen Z, Morrow S. Families’ Financial Stress & Well-­Being:The Importance
of the Economy and Economic Environments. J Fam Econ Issues 2020.
	18	 Chzhen Y. Perceptions of the economic crisis in Europe: do adults in households with
children feel a greater impact? Soc Indic Res 2016;127:341–60.
	19	 Masarik AS, Conger RD. Stress and child development: a review of the family stress
model. Curr Opin Psychol 2017;13:85–90.
	20	 Karanikolos M, Heino P, McKee M, et al. Effects of the global financial crisis
on health in high-­income Oecd countries: a narrative review. Int J Health Serv
2016;46:208–40.
	21	 Schnettler S, Klüsener S. Economic stress or random variation? Revisiting German
reunification as a natural experiment to investigate the effect of economic contraction
on sex ratios at birth. Environ Health 2014;13:117.
	22	 Burda MC, Hunt Jennifer (Jennifer Anne), Hunt JA. From reunification to economic
integration: productivity and the labor market in eastern Germany. Brookings Pap
Econ Act 2001;2001:1–92.
	23	 Robert Koch-­Institut. Inanspruchnahme pädiatrischer und allgemeinmedizinischer
Leistungen durch Kinder und Jugendliche in Deutschland – Querschnittergebnisse AUS
KiGGS Welle 2 und trends. RKI-­Bib1 (Robert Koch-­Institut), 2018.Available: https://​
edoc.rki.de/handle/176904/5872 [Accessed 07 Apr 2021].
	24	 Huang PL.A comprehensive definition for metabolic syndrome. Dis Model Mech
2009;2:231–7.
	25	 Austin PC.A tutorial and case study in propensity score analysis: an application
to estimating the effect of in-­hospital smoking cessation counseling on mortality.
Multivariate Behav Res 2011;46:119–51.
	26	 Bohley S, Kluttig A,Werdan K, et al. Changes of individual perception in psychosocial
stressors related to German reunification in 1989/1990 and cardiovascular risk factors
and cardiovascular diseases in a population-­based study in East Germany. BMJ Open
2016;6:e008703.
	27	 Hostinar CE, Ross KM, Chen E, et al. Early-­Life socioeconomic disadvantage and
metabolic health disparities. Psychosom Med 2017;79:514–23.
	28	 Al-­Hamad D, Raman V. Metabolic syndrome in children and adolescents. Transl Pediatr
2017;6:397–407.
	29	 Gardner DSL, Hosking J, Metcalf BS, et al. Contribution of early weight gain to
childhood overweight and metabolic health: a longitudinal study (EarlyBird 36).
Pediatrics 2009;123:e67–73.
	30	 Mucci N, Giorgi G, De Pasquale Ceratti S, et al.Anxiety, stress-­related factors, and
blood pressure in young adults. Front Psychol 2016;7:1682.
	31	 Yamamoto K, Okazaki A, Ohmori S.The relationship between psychosocial stress,
age, BMI, CRP, lifestyle, and the metabolic syndrome in apparently healthy subjects. J
Physiol Anthropol 2011;30:15–22.
	32	 Dearden L, Bouret SG, Ozanne SE. Sex and gender differences in developmental
programming of metabolism. Mol Metab 2018;15:8–19.
	33	 Dedovic K,Wadiwalla M, Engert V, et al.The role of sex and gender socialization in
stress reactivity. Dev Psychol 2009;45:45–55.
	34	 Ziol-­Guest KM, Duncan GJ, Kalil A. Early childhood poverty and adult body mass
index. Am J Public Health 2009;99:527–32.
	35	 Mrejen M, Machado DC. In utero exposure to economic fluctuations and birth
outcomes: an analysis of the relevance of the local unemployment rate in Brazilian
state capitals. PLoS One 2019;14:e0223673.
	36	 Solano ME, Jago C, Pincus MK, et al. Highway to health; or how prenatal factors
determine disease risks in the later life of the offspring. J Reprod Immunol
2011;90:3–8.
	37	 Rakers F, Rupprecht S, Dreiling M, et al.Transfer of maternal psychosocial stress to the
fetus. Neurosci Biobehav Rev 2020;117:185–97.
	38	 Forkel I, Silbereisen RK. Family economic hardship and depressed mood among young
adolescents from former East and West Germany. Am Behav Sci 2001;44:1955–71.
	39	 Priem M, Schupp J. Everyone happy: living standards in Germany 25 years after
reunification. DIW Econ Bull 2014;4:65–71.
	40	 Patino-­Alonso MC, Recio-­Rodríguez JI, Magdalena-­Belio JF, et al. Clustering of lifestyle
characteristics and their association with cardio-­metabolic health: the lifestyles and
endothelial dysfunction (evident) study. Br J Nutr 2015;114:943–51.
	41	 Atzendorf J,Apfelbacher C, de Matos EG, et al. Do smoking, nutrition, alcohol use,
and physical activity vary between regions in Germany? - results of a cross-­sectional
study. BMC Public Health 2020;20:277.
	42	 Lampert T, Mensink GBM, Romahn N, et al. Körperlich-­sportliche Aktivität
von Kindern und Jugendlichen in Deutschland: Ergebnisse des Kinder- und
Jugendgesundheitssurveys (KiGGS). Bundesgesundheitsblatt - Gesundheitsforschung Gesundheitsschutz
2007;50:634–42.
	43	 Goisis A, Özcan B,Van Kerm P. Do children carry the weight of divorce? Demography
2019;56:785–811.
	44	 Wang LX, Filipp SL, Urbina EM, et al. Longitudinal associations of metabolic syndrome
severity between childhood and young adulthood: the Bogalusa heart study. Metab
Syndr Relat Disord 2018;16:208–14.
Protectedbycopyright.
onDecember11,2024atMasarykuniversityinBrno.http://jech.bmj.com/JEpidemiolCommunityHealth:firstpublishedas10.1136/jech-2021-218637on23June2022.Downloadedfrom