Overweight and obesity: an emerging problem in patients with congenital heart disease

Impact of Underweight, Overweight, and Obesity on Health-Related Quality of Life in Children with Tetralogy of Fallot Variants

Traditional cardiovascular risk factors put patients with congenital heart disease (CHD) at increased risk for cardiovascular morbidity and mortality. The aim of this study was to evaluate whether body mass index (BMI) is associated with health-related quality of life (HRQoL) in patients with variants of Tetralogy of Fallot (TOF). Patients and parents of children with variants of TOF-CHD were asked to fill out the PedsQL 4.0 questionnaire and provide weight and length. Patients were categorized into low, normal, and high BMI percentiles. Other demographic data were obtained from the Swedish national registry for congenital heart disease (SWEDCON). Statistical analyses included non-parametric Mann-Whitney U test, Fisher exact, and Chi-square tests. Eighty-five patients were included. Twelve were overweight or obese, 57 had a normal BMI, and 16 were underweight. There was a significant difference in age and gender between the groups. Comparing overweight/obese children to those with normal BMI, physical and social functioning were impaired, while emotional and school function were comparable between the groups. This applied to both child and parental assessment. When comparing underweight to normal weight children, school functioning assessed by the parent was the only domain significantly different from patients with a normal BMI. Children with variants of TOF and overweight/obesity have lower HRQoL, particularly in physical and social functioning, while underweight children may have impaired school functioning. We suggest that preventive measures aimed at maintaining a normal weight should be taken early in life to reduce long-term cardiovascular risk in the CHD population.

Preoperative Feeding Fortification Among Infants with Congenital Heart Disease is Associated with Higher Growth Velocity in the First 30 Days Post-repair and Lower BMI Percentile for Age at 10 Years: A Retrospective Cohort Study

It remains unclear how preoperative nutrition fortification impacts postoperative growth trajectories and nutritional status among infants with congenital heart disease. A single center retrospective cohort study was performed to evaluate measures of growth among patients who underwent cardiac repair at 0-18 months of age for atrial septal defect, ventricular septal defect, atrioventricular septal defect, or tetralogy of Fallot. Cohorts were analyzed at 0-30 and 31-60 days post-repair as well as at 2, 5, and 10 years of age. Records of 24 patients who received fortified nutrition and 60 patients who received unfortified nutrition preoperatively were reviewed. Those with fortified nutrition had higher growth velocities in the first 30 days post-repair compared to those with unfortified nutrition: 28.4 (23.8-83.3) grams per day versus 16.7 (7.1-21.4) grams per day, p = 0.004. Weight percentile for age was higher in the unfortified group at 2, 5, and 10 years of age (p = 0.02, p = 0.045, and p = 0.01). Body mass index (BMI) percentile for age was higher in the unfortified group at 5 and 10 years of age (p = 0.045 and p = 0.02) with a trend toward higher prevalence of either overweight or obesity compared to the fortified group (p = 0.13). reoperative nutrition fortification among infants with congenital heart disease is associated with higher growth velocity in the first 30 days post-repair and lower BMI percentile for age at 10 years. Further studies are needed to evaluate the association between preoperative nutrition fortification and postoperative outcomes, nutritional status, and prevalence of obesity in adolescence and adulthood.

Body composition in patients with Fontan physiology: a systematic review

Fontan circulation is a highly abnormal circulatory state that may affect various organ systems. The effect on body composition is an important factor to assess the condition of the patient. This systematic review assesses body composition and possibly related adverse outcomes in patients with a Fontan circulation, to provide an overview of current insights. Studies evaluating body composition by compartment (either fat mass or lean/muscle mass) in Fontan patients published up to April 2023 were included in this systematic review. Of 1392 potential studies, 18 studies met the inclusion criteria. In total, body composition measurements of 774 Fontan patients were included. Body composition was measured using dual-energy X-ray absorptiometry (DXA) (n = 12), bioelectrical impedance analysis (BIA) (n = 5), computer tomography (CT) (n = 1), or magnetic resonance imaging (MRI) (n = 1). All studies reported a normal body mass index (BMI) in Fontan patients, compared to controls. Five out of nine studies reported significantly higher body fat values, and twelve out of fifteen studies reported significantly lower muscle or lean mass values in the Fontan population compared to the healthy population. Unfavorable body composition in Fontan patients was associated with decreased exercise capacity, worse cardiac function, and adverse outcomes including hospital admissions and death.   Conclusions: Despite having a normal BMI, Fontan patients have an increased fat mass and decreased muscle mass or lean mass compared to the healthy population. This unfavorable body composition was associated with various adverse outcomes, including a decreased exercise capacity and worse cardiac function. What is Known: • Patients with a Fontan circulation have a decreased exercise capacity compared to healthy peers, an unfavorable body composition might be a contributor to their impaired exercise capacity. What is New: • Fontan patients are predisposed to an unfavorable body composition, characterized by increased fat mass and decreased muscle mass accompanied by a normal BMI compared to the healthy population. • Among others, unfavorable body composition was associated with decreased exercise capacity, cardiac function, and increased morbidity in patients with a Fontan circulation.

Facilitators and barriers of physical activity participation in children with a single ventricle physiology: a mixed-methods study

BACKGROUND

The present study focuses on assessing the physical activity level of children with Fontan circulation for Hypoplastic Left Heart Syndrome and identifying potential barriers and facilitators toward their participation in physical activity.

PATIENTS AND METHODS

Seven children aged 5-16 years (mean (SD) 8.8 (3.7) years) with a Fontan procedure for hypoplastic left heart syndrome, their parents (n = 7), and siblings (n = 1) were recruited. Data were collected using a mixed-methods approach: (i) children wore an activity monitor for 7 days to record physical activity, with sedentary time and level of activity calculated from accelerometer data; (ii) children completed a bespoke questionnaire recording limitations in physical activity; (iii) parents completed a semi-structured interview discussing perceptions about their child's physical activity participation. Qualitative data were analysed using thematic analysis.

RESULTS

Activity monitors data recorded highly active children with a mean (SD) of 153(36) minutes/day spent in moderate-to-vigorous physical activity. Time spent in sedentary behaviour was also high (57.5% of total accelerometer wearing-time). Four key themes relating to parental perceptions of physical activity were identified: (i) A new lease of life -post-Fontan; (ii) Setting limits - managing limitations; (iii) The wider world - how others set limits; and (iv) "I fear the future" - parental concerns.

CONCLUSION

Following completion of the Fontan circulation, children engaged in higher levels of physical activity in comparison to the national average. However, more than half their time was spent in sedentary behaviour. Fears and anxiety from parents and teachers may act as a barrier toward physical activity participation.

Childhood Obesity and Congenital Heart Disease: A Lifelong Struggle

Congenital heart disease (CHD) affects approximately one in every one hundred infants worldwide, making it one of the most prevalent birth abnormalities globally. Despite advances in medical technology and treatment choices, CHD remains a significant health issue and necessitates specialized care throughout an individual's life. Childhood obesity has emerged as a novel global epidemic, becoming a major public health issue, particularly in individuals with lifelong conditions such as CHD. Obesity has profound effects on cardiac hemodynamics and morphology, emphasizing the importance of addressing obesity as a significant risk factor for cardiovascular health. Obesity-induced alterations in cardiac function can have significant implications for cardiovascular health and may contribute to the increased risk of heart-related complications in obese individuals. Moreover, while diastolic dysfunction may be less apparent in obese children compared to adults, certain parameters do indicate changes in early left ventricular relaxation, suggesting that obesity can cause cardiac dysfunction even in pediatric populations. As most children with CHD now survive into adulthood, there is also concern about environmental and behavioral health risk factors in this particular patient group. Addressing obesity in individuals with CHD is essential to optimize their cardiovascular health and overall quality of life. This review aims to succinctly present the data on the impact of obesity on CHD and to enhance awareness of this perilous association among patients, families, and healthcare providers.

Effects of Sports, Exercise Training, and Physical Activity in Children with Congenital Heart Disease-A Review of the Published Evidence

Children and adolescents with congenital heart disease (CHD) should be encouraged to adopt a physically active lifestyle, ideally by participating in sports activities at school and sports clubs. Children with complex CHD or other risk factors (for example, pacemakers, cardioverter-defibrillators, channelopathies) may, however, need specific individualized training programs. This review article summarizes the current knowledge regarding the clinical effects of sports and exercise training on CHD and its pathophysiologic mechanisms. An evidence-based approach based on a literature search, using PubMed, Medline, CINHAL, Embase, and the Cochrane Library was conducted, last completed on 30 December 2021. In studies with 3256 CHD patients in total, including 10 randomized controlled trials, 14 prospective interventional trials, 9 observational trials, and 2 surveys, exercise training has been shown to improve exercise capacity and physical activity, motoric skills, muscular function, and quality of life. Sports and exercise training appears to be effective and safe in CHD patients. Despite being cost-efficient, training programs are currently scarcely reimbursed; therefore, support from healthcare institutions, commissioners of healthcare, and research-funding institutions is desirable. There is a strong need to establish specialized rehabilitation programs for complex CHD patients to enhance these patients' access to this treatment intervention. Further studies may be desirable to confirm these data to investigate the impact on risk profiles and to identify the most advantageous training methodology and underlying pathophysiological mechanisms.

Body Mass Index Trajectory and Outcome Post Fontan Procedure

Background Patients with a single ventricle who experience early life growth failure suffer high morbidity and mortality in the perisurgical period. However, long-term implications of poor infant growth, as well as associations between body mass index (BMI) and outcome in adulthood, remain unclear. We aimed to model BMI trajectories of patients with a single ventricle undergoing a Fontan procedure to determine trajectory-based differences in baseline characteristics and long-term clinical outcomes. Methods and Results We performed a retrospective analysis of medical records from patients in the Australia and New Zealand Fontan Registry receiving treatment at the Royal Children's Hospital, The Children's Hospital at Westmead, Royal Melbourne Hospital, and Royal Prince Alfred Hospital from 1981 to 2018. BMI trajectories were modeled in 496 patients using latent class growth analysis from 0 to 6 months, 6 to 60 months, and 5 to 16 years. Trajectories were compared regarding long-term incidence of severe Fontan failure (defined as mortality, heart transplantation, Fontan takedown, or New York Heart Association class III/IV heart failure). Three trajectories were found for male and female subjects at each age group-lower, middle, higher. Subjects in the lower trajectory at 0 to 6 months were more likely to have an atriopulmonary Fontan and experienced increased mortality long term. No association was found between higher BMI trajectory, current BMI, and long-term outcome. Conclusions Poor growth in early life correlates with increased long-term severe Fontan failure. Delineation of distinct BMI trajectories can be used in larger and older cohorts to find optimal BMI targets for patient outcome.

Being Overweight Is Related to Neoaortic Sinus Dilatation After Arterial Switch Operation

Background

Neoaortic sinus dilatation is a late comorbidity after an arterial switch operation in patients with dextro-transposition of the great arteries. We aim to explore whether neoaortic sinus dilatation is related to overweight or obesity, as these affect aortic remodeling in such patients.

Methods

We measured neoaortic diameters including those for the annulus, sinus, sinotubular junction, and ascending aorta by echocardiography and studied the relationship between these diameters and body mass index in patients aged 15 years and older after an arterial switch operation.

Results

A total of 45 patients were studied. Median (interquartile range) age, body mass index, and systolic blood pressure at echocardiography were 20 (17–28) years, 21.2 (18.4–24.2) kg/m2, and 120 (112–127) mm Hg, respectively. Echocardiogram revealed the following median values (interquartile ranges): neoaortic annulus diameter, 22.2 (19.8–23.8) mm; sinus diameter, 34.6 (31.8–39.8) mm; sinotubular junction diameter, 27.5 (22.4–30.0) mm; and ascending aortic diameter, 20.4 (19.4–22.7) mm. The neoaortic sinus diameter was significantly correlated with body mass index (r = 0.41, P = .004) and was significantly larger in patients with concomitant ventricular septal defect (P < .001) and those who were over-weight (body mass index ≥25 kg/m2; P = .006).

Conclusion

Neoaortic sinus dilatation after an arterial switch operation is associated with being overweight during adolescence and young adulthood. It is important to prevent obesity in patients after an arterial switch operation and educate them on a healthy lifestyle.

Ultra-processed food intake is associated with children and adolescents with congenital heart disease clustered by high cardiovascular risk factors

The excessive intake of ultra-processed foods (UPF) is associated with an increase in cardiovascular risk. However, the effect of UPF intake on cardiovascular health in children and adolescents with congenital heart disease (CHD) is unknown. The aim of the present study was to describe UPF intake and evaluate associations with isolated cardiovascular risk factors and children and adolescents with CHD clustered by cardiovascular risk factors. A cross-sectional study was conducted involving 232 children and adolescents with CHD. Dietary intake was assessed using three 24-hour recalls. UPFs were categorized using the NOVA classification. The cardiovascular risk factors evaluated were central adiposity, elevated high-sensitivity C-reactive protein (hs-CRP) and subclinical atherosclerosis. The clustering of cardiovascular risk factors (waist circumference, hs-CRP and carotid intima-media thickness) was performed, allocating the participants to two groups (high versus low cardiovascular risk). UPFs contributed 40.69% (SD 6.21) to total energy intake. The main UPF groups were ready-to-eat and take-away/fast foods (22.2% energy from UPFs). The multivariable logistic regression revealed that an absolute increase of 10% in UPF intake (OR=1.90; 95% CI: 1.01;3.58) was associated with central adiposity. An absolute increase of 10% in UPF intake (OR=3.77; 95% CI: 1.80;7.87) was also associated with children and adolescents with CHD clustered by high cardiovascular risk after adjusting for confounding factors. Our findings demonstrate that UPF intake should be considered a modifiable risk factor for obesity and its cardiovascular consequences in children and adolescents with CHD.

Describing characteristics of adults with and without congenital heart defects hospitalized with COVID-19

Background

We sought to describe patient characteristics in adults with and without congenital heart defects (CHDs) during hospitalization for COVID‐19.

Methods

We analyzed data collected by Optum®, a nationally representative database of electronic medical records, for 369 adults with CHDs and 41,578 without CHDs hospitalized for COVID‐19 between January 1, 2020, and December 10, 2020. We used Poisson regression to describe and compare epidemiologic characteristics, heart‐related conditions, and severe outcomes between these two groups.

Results

The distributions of many epidemiologic characteristics were similar between the two groups, but patients with CHDs were significantly more likely to be current or former smokers compared to patients without CHDs (risk ratio [RR]: 1.5, 95% confidence interval [CI]: 1.2, 1.8). Patients with CHDs were also significantly more likely to have heart failure, stroke, acute arrhythmia, myocardial injury, acute pulmonary hypertension, venous thromboembolism, and obesity documented at the time of the COVID‐19 hospitalization (RR range: 1.5–4.7) but not respiratory failure. Patients with CHDs (7 days) had a significantly longer median length of stay than those without CHDs (5 days; p < .001) and were significantly more likely to have an intensive care unit (ICU) admission (RR: 1.6, 95 CI: 1.2–1.9).

Conclusions

Our description of patients among a large population improves our understanding of the clinical course of COVID‐19 among adults with CHDs. Adults with CHD appear to be at greater risk for more severe CHD, including greater risk of ICU admission and longer length of hospital stays.

Differences in Cardiopulmonary Fitness Between Boy and Girls With Repaired Tetralogy of Fallot

OBJECTIVE

Many studies have demonstrated that patients with repaired tetralogy of Fallot (rTOF) have generally poorer cardiopulmonary fitness (CPF). However, little is known about how the disease results in different CPF in each sex. Therefore, this study aimed to investigate whether sex (and gender) differences affect CPF in children and adolescents with rTOF.

METHODS

This retrospective study recruited adolescents and children (aged 10-18) with rTOF following an acute stage of tetralogy of Fallot (TOF) who received cardiopulmonary exercise testing (CPET) in the past 10 years. CPF was determined by symptom-limited CPET with a treadmill under ramped Bruce protocol. Boys and girls were categorized into groups based on body mass index (BMI) and fat mass index (FMI). The BMI was grouped by Taiwanese obesity cutoff points. The FMI was categorized by the body fat percentage. Excess adiposity was defined as (1) "overweight" and "obese" by BMI and (2) greater than the sex- and age-specific 75th percentile of whole subjects by FMI.

RESULTS

A total of 185 participants (104 boys and 81 girls) with rTOF were recruited for the final analysis. Within the BMI category, 76 boys and 63 girls were in the normal group, whereas 28 boys and 18 girls were in the excessive adiposity group. Within the FMI category, 77 boys and 60 girls were in the normal group, whereas 27 boys and 21 girls were in the excessive adiposity group. The analysis of the body composition of rTOF subjects showed that there was no statistically significant difference between the subgroups of the two sexes, but both showed a smaller body size than normal Taiwanese children. When comparing the CPF within different BMI and FMI groups, the children in the excessive adiposity group had significantly lower values in metabolic equivalents (MET) at anaerobic threshold, peak MET, and measured peak oxygen consumption (VO₂) to predicted peak VO₂, regardless of sex. Moreover, boys (60.90%) presented poorer CPF than girls (74.22%, p < 0.001).

CONCLUSION

In Taiwan, patients with rTOF had poorer CPF than healthy peers. This study found that girls with rTOF had better CPF than boys with rTOF. The effect of gender stereotypes on sports participation and self-efficacy might be one of the contributing factors; however, further investigations are warranted to determine the causal effect.

Making every contact count: recognising obesity in paediatric and young adult cardiology

INTRODUCTION

With increased survival, children with CHD are reaching adulthood, however, obesity amongst this cohort is an emerging problem. Making every contact count encourages clinicians to utilise contact to elicit behaviour change. The aim of this work was to identify whether the body habitus of children classified as obese was addressed during a clinical review.

METHODS

A retrospective observational cohort study was completed using a cardiology outpatient dataset from 2010 to 2019. Inclusion criteria are all children with a body mass index z score classified as obese (≥ 2 z scores). Individual electronic patient records were reviewed to identify long-term anthropometric measures including (i) recognition of body habitus, (ii) prescription of physical activity or dietary intervention, and (iii) referral to a weight management programme or dietitian.

RESULTS

From the cohort of 95 patients, 285 "obese clinical encounters" were identified, at the time of a cardiology clinic attendance. Of those, obesity was acknowledged in 25 clinic letters (8.65%), but only 8 used the correct terms "obese" or "obesity" (2.77%). Action to tackle obesity was recorded in 9.3% of cases with a direct referral to a dietitian being made on 3 occasions (1.04%).

CONCLUSIONS

Body habitus is not being routinely addressed by cardiologists caring for paediatric and young adult cardiac patients. This study has recognised an alarmingly high incidence of missed opportunities to make every contact count, to manage those with obesity and associated risk factors.

[Managing transition - Medical follow-up care for adults with congenital heart defects]

Currently, due to medical advances, more than 500 000 patients with congenital heart defects (CHD) are living in Germany, including more than 330 000 adults. In CHD, the aspect of transition from childhood and adolescence to adulthood is becoming increasingly important to ensure long-term success of the provided treatments. This is so important because despite primarily successful treatments, residua and sequels as well as (non-) cardiac comorbidities may influence the chronic course of the disease and lead to increased morbidity and mortality. Adults with congenital heart defects in Germany are insufficiently managed by existing specialized and accredited care structures, despite the great need for follow-up, and their care is largely provided by primary care physicians (general practitioners and internists) and non-specialized cardiologists.Optimized, future-oriented care requires regular follow-up and the possibility of interdisciplinary, integrated medical care of CHD in the long-term course.

Impact of body mass index on primary immunoglobulin A nephropathy prognosis: a systematic review and meta-analysis

PURPOSE

The impacts of body mass index (BMI) on the prognosis of primary IgA nephropathy (IgAN) remain controversial. This systematic review and meta-analysis aimed to solve these issues.

METHODS

We searched the PubMed, EMBASE, and Cochrane Library to screen articles investigating the BMI and primary IgAN. BMI was classified according to the World Health Organization as high (≥ 25.0 kg/m²) and low (< 25.0 kg/m²). The baseline renal indexes and the incidences of adverse renal outcomes were focused on.

RESULTS

Six studies with a total of 1723 patients were included in this study. High BMI was demonstrated to be associated with increased baseline levels of serum creatinine (weighted mean difference (WMD) 9.54, 95% confidence interval (CI) 0.63-18.45), blood uric acid (WMD 19.85, 95% CI 10.11-29.59) and urine protein (WMD 0.37, 95% CI 0.21-0.53). Patients with high BMI also showed compromised eGFR at diagnosis (WMD - 8.39, 95% CI - 11.62 to - 5.16) with a higher incidence rate of hypertension (odds ratios (OR) 2.59, 95% CI 1.44-4.66) and higher global optical scores (WMD 1.22, 95% CI 0.70-1.74). Regarding the prognosis, high BMI was significantly associated with the incidence of adverse renal outcomes (OR 2.43, 95% CI 1.66-3.55, P < 0.001) and deteriorated eGFR at the last follow-up (WMD - 11.10, 95% CI - 16.96 to - 5.25, P < 0.001), with non-significantly poorer renal disease-free survival (hazard ratio 1.79, 95% CI 0.58-5.50, P = 0.31).

CONCLUSION

High BMI was associated with severe onset and poor prognosis of primary IgAN. The management of BMI could be a novel method to promote the therapeutic outcomes of primary IgAN.

Somatic growth in children with congenital heart disease at 10 years of age: Risk factors and longitudinal growth

BACKGROUND

Children with congenital heart disease (CHD) are at risk of impaired growth.

AIMS

To describe height, weight, head circumference (HC), and body mass index (BMI) at 10 years and identify risk factors for altered longitudinal growth in children with CHD.

STUDY DESIGN

Growth parameters were evaluated from birth until 10 years using z-scores. The impact of cardiac and noncardiac factors on longitudinal growth was investigated.

SUBJECTS

A total of 135 children with different types of CHD who underwent cardiopulmonary bypass surgery, no genetic disorder.

OUTCOME MEASURES

Head circumference, weight, height and BMI.

RESULTS

At 10 years, z-scores for height and BMI did not differ from the Swiss population (P > 0.1). Z-scores for weight and HC were significantly below the norm (-0.38 and - 0.71, P < 0.01). From 1 to 10 years, all growth parameters except BMI increased significantly (P ≤ 0.001, BMI: P = 0.14). Lower gestational age and longer length of hospitalization were associated with either impaired head circumference or length at 10 years, while lower socioeconomic status was associated with higher BMI and weight at 10 years (all P < 0.05).

CONCLUSION

Despite partial catch-up, somatic growth remains impaired in children with CHD with weight and HC below the norm at 10 years. The only cardiac factor associated with impaired longitudinal growth was duration of hospital stay. Furthermore, lower socioeconomic background may pose a risk of overweight at older age. Close monitoring of growth parameters and parental counselling in all CHD children is advisable beyond early childhood to ensure optimal somatic growth.

Systematic assessment of health care perception in adults with congenital heart disease in Germany

BACKGROUND

The number of adults with congenital heart disease (ACHD) is steadily rising due to increased survival rate and improved medical resources. Accordingly, more than 330,000 ACHD are currently living in Germany. Almost all of them require lifelong specialized medical follow-up for their chronic heart disease, often accompanied by residua, sequelae, or comorbidities. Primary care physicians (PCPs) are a crucial factor in directing patients to ACHD specialists or specialized institutions, but despite all efforts, the number of ACHD under specialized care is low, the lost-to-follow-up rate is high, and the morbidity and mortality is substantial. The present cross-sectional study was designed to systematically characterize the health care of ACHD from a patient perspective, including (I) use of medical care by ACHD, (II) medical counselling needs, and (III) perceived satisfaction with health care.

METHODS

The German-wide analysis was based on a 25-item questionnaire designed to address different aspects of medical status and health issues of ACHD from their own perspective, performed between May of 2017 and July of 2020.

RESULTS

A total of 4,008 ACHD (52% female; mean age 41.9±17.2 years) completed the questionnaire. The majority of ACHD (3,524, 87.9%) reported, that they consulted their PCP for non-cardiac health problems, and 49.7% (n=1,991) consulted their PCP also for medical problems associated with the underlying CHD. Almost all ACHD reported a need for medical advice concerning exercise capacity and daily life activities, occupational skills, pregnancy, rehabilitation, genetic counselling, insurance, and retirement. A total of 1,840 (45.9%) patients were not aware of the existence of certified ACHD specialists or centers. Moreover, 2,552 (67.6%) of those surveyed were uninformed about patient organizations for ACHD.

CONCLUSIONS

The present study demonstrates that ACHD are largely uninformed about the ACHD care structures available nationwide, although the patients have a great need for specialized follow-up, advice, and care.

Physical activity in children and adolescents with CHD: review from a measurement methodological perspective

AIM

To compile a literature overview of physical activity in children with CHD and to critically evaluate the methodology used for physical activity assessment.

METHODS

A review of the literature was performed using PubMed to identify studies examining accelerometer and subjectively assessed physical activity in children and adolescents with CHD.

RESULT

A total of 15 studies were included (6 studies using subjective measures and 9 articles using accelerometers for the assessment of physical activity). The patients generally failed to meet the recommendations of physical activity. When compared to healthy controls, the results were widely divergent in the subjectively assessed measures and the accelerometer-based studies showed a tendency of no difference in physical activity. Neither subjective methods nor accelerometer-based studies reported any difference in physical activity in general, in relation to the severity of the heart disease.

CONCLUSION

Methodological variation and limitations in the assessment of physical activity largely explain the divergent results and the inability to establish differences in physical activity between children with CHD of different severity and compared to healthy controls. Methodological knowledge and guidelines are provided for improved assessment of physical activity using accelerometers in clinical research.

Heart failure in adult congenital heart disease: tetralogy of Fallot

The number of rTOF patients who survive into adulthood is steadily rising, with currently more than 90% reaching the third decade of life. However, rTOF patients are not cured, but rather have a lifelong increased risk for cardiac and non-cardiac complications. Heart failure is recognized as a significant complication. Its occurrence is strongly associated with adverse outcome. Unfortunately, conventional concepts of heart failure may not be directly applicable in this patient group. This article presents a review of the current knowledge on HF in rTOF patients, including incidence and prevalence, the most common mechanisms of heart failure, i.e., valvular pathologies, shunt lesions, left atrial hypertension, primary left heart and right heart failure, arrhythmias, and coronary artery disease. In addition, we will review information regarding extracardiac complications, risk factors for the development of heart failure, clinical impact and prognosis, and assessment possibilities, particularly of the right ventricle, as well as management strategies. We explore potential future concepts that may stimulate further research into this field.

Associations between weekly air pollution exposure and congenital heart disease

BACKGROUND

The topic of congenital heart diseases (CHDs) has attracted more and more attentions. Accumulating evidence suggests that exposure to air pollutants during pregnancy is associated with CHDs, yet the results are inconsistent and study about weekly exposure is few. Our study evaluated the association between weekly air pollution and CHDs in Hefei, China.

MATERIALS AND METHODS

Daily CHDs admission data were obtained from eight hospitals in Hefei from October 2015 to September 2017. Meteorological data and air quality were collected from China Meteorological Data Network. Distributed lag nonlinear model (DLNM) considering both the lag effect of exposure factors and the nonlinear relationship of exposure-reaction was used to assess the effect of weekly air pollutants exposure on CHDs admission.

RESULTS

During the study period, totally 47,046 cases of perinatal infants were recruited, and the incidence of CHDs was 9.71 per thousand. The findings showed PM_2.5, PM₁₀, SO₂ and NO₂ significantly increased the risk of CHDs. Each 10 μg/m³ increase in PM_2.5 during gestational weeks 20-26 increased the risk of CHDs. The susceptibility windows of PM₁₀ (weeks 0-2 and weeks 25-29 of pregnancy), SO₂ (weeks 8-16 and weeks 29-38) and NO₂ (week 40), while the strongest effects of these 4 pollutants on CHDs were observed in week 22 (RR = 1.034, 95% CI: 1.007-1.062), week 0 (RR = 1.081, 95% CI: 1.02-1.146), week 37 (RR = 1.528, 95% CI: 1.085-2.153) and week 40 (RR = 1.171, 95% CI: 1.006-1.364), respectively.

CONCLUSIONS

Air pollutants (SO₂, NO₂, PM₁₀, and PM_2.5) exposure could increase the risk of CHDs, while the most crucial susceptibility windows for the exposure were mainly in the second and third trimesters. Boys seemed to be more sensitive to air pollution. Our study contributes to the knowledge of the association between maternal exposure to air pollution and CHDs, but the associations need to be verified by further studies.

Epidemiology, Predisposing Factors, Biomarkers, and Prevention Mechanism of Obesity: A Systematic Review

Background. Globally, obesity is becoming a public health problem in the general population. Various determinants were reported by different scholars even though there are inconsistencies. Different biomarkers of obesity were identified for the prediction of obesity. Even though researchers speculate the factors, biomarkers, consequences, and prevention mechanisms, there is a lack of aggregate and purified data in the area of obesity. Summary. In this review, the epidemiology, predisposing factors, biomarkers, consequences, and prevention approaches of obesity were reviewed. Key Messages. The epidemiology of obesity increased in low-, middle-, and high-income countries. Even if the factors vary across regions and socioeconomic levels, sociodemographic, behavioral, and genetic factors were prominent for the development of obesity. There are a lot of biomarkers for obesity, of which microRNA, adipocytes, oxidative stress, blood cell profile, nutrients, and microbiota were promising biomarkers for determination of occurrence of obesity. Since the consequences of obesity are vast and interrelated, multidimensional prevention strategy is mandatory in all nations.