Objectives Maternal famine exposure has been associated with higher blood pressure in the offspring. The aim of the present study was to examine the associations of early life exposure to the 1959-1961 Chinese famine with the risk of hypertension in later life, and to examine whether a nutritional 'rich' environment in later life modifies this association. Methods We used data of 7874 adults born between 1954 and 1964 from the 2002 China National Nutrition and Health Survey. Excess death rate was used to determine the severity of the famine. Results In severely affected famine areas, as compared to adults who were not exposed to famine, those exposed during fetal life had a significantly higher SBP [SBP difference 2.2 mmHg, 95% confidence interval (CI) 1.3-3.0, P<0.0001], DBP (DBP difference 0.9 mmHg, 95% CI 0.3-1.5, P=0.003) and a marginally higher risk of hypertension (odds ratio 1.88, 95% CI 1.00-3.53, P=0.05), after adjustment of age, sex, socioeconomic status, lifestyle, dietary factors and family history of hypertension, which was not observed in less severely affected famine areas (P for interaction was 0.08 for SBP, 0.03 for DBP and 0.03 for hypertension). These associations were more pronounced in participants who had a western dietary pattern or who were overweight as adult. Conclusion Our results suggest that fetal famine exposure is associated with higher blood pressure and an increased risk of hypertension in adulthood. These associations are stronger in participants who have a western dietary pattern or who are overweight as adults. J Hypertens 29: 1085-1092 (C) 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.