Survival has improved in recent decades for infants with congenital heart disease (CHD), resulting in a rapidly growing population needing lifelong care.1 More than half of children and adolescents with CHD have early signs of atherosclerosis.2 As CHD survivors age, they are susceptible to additional cardiovascular comorbidities that are known to be hastened by obesity in the general population (ie, coronary artery disease, hypertension, and heart failure), resulting in premature mortality.2 Recent studies from the United States have reported similar rates of obesity between adult CHD survivors and non-CHD controls matched on age, sex,3 and, for 1 study, race/ethnicity,4 which is alarming given that CHD survivors have an elevated risk of future cardiovascular complications and other comorbidities as a consequence of their disease. One study demonstrated that adult non-Hispanic (NH) black CHD survivors are more likely to be obese as compared with NH white CHD survivors,3 which is also true in the general population.5,6 Despite the growing literature on obesity in CHD, rates of obesity among NH black children and adolescents with CHD remain unknown.
Racial disparities between mortality and other outcomes have been identified among CHD survivors.7,8 Mortality is higher across the lifespan for NH black CHD survivors as compared with NH white survivors.7 The same disparities are seen with higher rates of post–cardiac surgery mortality, which is not accounted for by access to care.8 Given that obesity is likely contributing to premature mortality and morbidity among CHD survivors,2 NH blacks may be at a particular risk given the higher rates of obesity in the general population.
The aim of the current retrospective study was to compare national obesity data with rates of overweight and obesity in NH black and NH white CHD survivors across multiple age ranges, as well as to characterize racial disparities in overweight and obesity.
All patients seen at a pediatric and an adult medical center in 2007 to 2013 were included if they (a) had structural CHD per International Classification of Diseases, Ninth Revision, codes (397.0, 745, 746, 747.2, 747.3, 747.31, 747, and 747.60); (b) were 6 years or older; and (c) had a recorded height, weight, and race (self-reported “NH white” or “NH black”) at their most recent visit. The study protocol obtained a priori approval by the institutional review board. Body mass index was categorized as normal, overweight, or obese based on 2000 Centers for Disease Control and Prevention growth standards for age and sex for patients younger than 18 years9 and body mass index of less than 25 (normal), 25.0 to 29.9 (overweight), and 30.0 or greater (obese) for patients 18 years or older.6 Underweight individuals were excluded from analyses as underweight status was outside the scope of current investigation. Lesion severity was determinable for 78% of the records retrieved and was denoted as simple, moderate, or complex, using the American College of Cardiology/American Heart Association 2008 guidelines for managing adults with CHD.1 Analyses only included those for whom lesion severity was determinable. Demographics and insurance status were recorded as part of clinical care. The national prevalence of overweight and obesity was based on weighted estimates from the National Health and Nutrition Examination Assessment Survey (NHANES) 2013–2014 of the same age and racial groups.10 χ2 Statistics determined whether the proportions of overweight and obesity differed between CHD survivors and the NHANES sample. Risk ratios comparing NH black with NH white CHD survivors on the risk of overweight and obesity, with normal weight as a reference, were estimated using log-binomial regression, controlling for lesion severity and health insurance status. Models were stratified by age (children, 6–12 years; adolescents, 13–18 years; young adults, 19–39 years; adults, 40+ years) based on Wald P < .20 for an interaction term in the regression model testing age as an effect modifier.
The proportion of the 4496 CHD survivors (4050 NH white and 446 NH black; 52% male) who were normal weight, overweight, or obese can be seen in classification in the Figure. The sample had a range of lesion severities (simple, 36%; moderate, 50%; and complex, 14%). Significant differences were identified in the proportion of lesion severities across the age groups (χ2 = 137.1, P < .001), such that young adults had the highest proportion of complex CHD (20% vs 15% [children], 12% [adolescents], and 8% [adults]) and children had the highest proportion of simple lesion types (43% vs 39% [adolescents], 24% [young adults], and 33% [adults]). Differences were also found in lesion severities across race (χ2 = 23.4, P < .001), such that NH white participants had a higher proportion of moderate lesion types (52% vs 40% NH black) and NH black survivors demonstrated higher proportions of simple lesion types (33% vs 45% NH white). Comparing CHD survivors with the NHANES sample, NH white children with CHD had a higher prevalence of obesity (18.6%) as compared with NH white children of the same age (13.8%) (χ2 = 14.91, P < .01). In contrast, NH white young adults with CHD had a lower prevalence of obesity (27.4%) as compared with NH white young adults from NHANES (31.1%) (χ2 = 9.27, P < .01). There were no statistically significant differences between adolescent NH white CHD survivors and adolescents in the NHANES sample (19.8% vs 20.8%), as well as NH black CHD survivors of all ages and the NHANES sample (eg, young adult CHD survivors, 42.2%; NHANES, 36.2%).
Log-binomial regressions, stratifying by age, showed a large black-white disparity in obesity among CHD survivors emerging in adolescence, which persisted into adulthood. After controlling for lesion severity and insurance status, the difference among adolescents was no longer statistically significant, but differences for the other age groups remained significant such that NH blacks with CHD had a 58% increased risk of obesity in young adulthood and a 33% increased risk in late adulthood compared with NH whites with CHD (Table). The risk of being overweight for NH blacks was not statistically different than for NH whites in any age group.
This is the first study to identify rates of obesity among CHD survivors across multiple age groups as compared with US national data, as well as the first study to report rates of overweight and obesity specific to child and adolescent NH black CHD survivors. This is also the largest sample of NH black CHD survivors for which overweight and obesity have been examined. The finding that CHD survivors, a population at risk for significant cardiovascular morbidity, have similarly high rates of overweight and obesity as the general population is alarming. Although advancements in medicine have allowed individuals with CHD to survive into adulthood, obesity is contributing to morbidity and premature mortality in this aging population.2 A recent study found altered levels of total cholesterol in almost half of the 316 children and adolescents with CHD seen in an outpatient clinic, with approximately 27% also having excess weight.11 Among adults with CHD, increases in emergency department admissions have been documented, suggesting rises in hypertension, diabetes, and obesity.12 Undoubtedly, the management of CHD survivors across the lifespan is complex and requires attention to more than only their cardiac lesion.
Higher rates of obesity identified among NH white children with CHD as compared with national data are particularly concerning given evidence that atherosclerotic processes are accelerated among child and adolescent CHD survivors.13 These data suggest that interventions to promote weight loss and/or reduce risk factors for obesity (eg, inactivity, poor dietary behaviors) should start in childhood and extend across the lifespan for all CHD survivors. This may include physical activity interventions, which should align with current recommendations for most children with CHD14 and children in the general population: 60 minutes or longer of moderate-to-vigorous physical activity per day. Parental overprotection has been noted as a possible contributor for lower rates of physical activity, especially among those with complex CHD,15 which may contribute to the development of overweight and obesity at earlier stages than the general population. Healthcare providers should educate parents about physical activity and weight management recommendations in early childhood, which may help prevent overprotection or misunderstandings about what their child can and cannot do for physical activity, as well as monitor weight gain as CHD survivors age.
Similar to the general population, evidence of racial disparities in obesity was found among CHD survivors after adolescence. The staggering rates of obesity among NH black CHD survivors in adulthood may be an important driver of worse outcomes, especially given that NH blacks also have a higher incidence of obesity-related morbidities, such as high blood pressure and diabetes.16 A recent review of obesity interventions among NH blacks suggests that weight loss outcomes remain understudied for this population, but evidence has emerged that culturally tailored intervention materials may enhance outcomes.17 There may be additional important considerations for developing successful interventions for weight loss among NH blacks with CHD yet to be identified among this grossly understudied and at-risk population.
The higher proportion of simple lesion types found among NH black CHD survivors, and conversely lower proportion of moderate lesion types as compared with NH white survivors, may point to another racial disparity pertinent to CHD care. Although the retrospective nature and scope of the current study limit the extent to which these findings can be interpreted, they can serve as a call for further investigation into whether NH blacks with moderate disease severity may have poorer outcomes, including a higher mortality rate, resulting in fewer represented among those currently engaged in care.
Surprisingly, NH white young adults with CHD were found to have a lower prevalence of obesity than those in the general population of the same race and age group. One explanation could be the higher proportion of complex CHD represented in young adults as compared with the other age groups. However, those with univentricular anatomy are known to be at a greater risk for being overweight or obese in adulthood,18 and the current study controlled for disease severity in analyses. The traditional designation of “simple,” “moderate,” and “complex” may not adequately account for differences in outcomes compared with a functional limitation rating, such as the New York Heart Association functional class.19,20 Other aspects of having complex disease that could contribute to lower weight and that are not accounted for by the traditional designations may be confounds.
The current study had several limitations. First, the data were acquired from 1 metropolitan area in the Midwest and may not be representative of other areas in the United States, including those with a higher proportion of NH blacks. Despite this, the current study provides more generalizability given that data were from both a pediatric and an adult facility, which are not typically represented in single-center studies. Second, the sample size was relatively small for NH blacks within each age category and weight status group. Small sample sizes may reduce power to detect differences between NH black and NH white CHD survivors, as well as between NH black CHD survivors and NH blacks from the general population, as provided by NHANES. Despite this, statistically significant differences were identified between NH black and NH white CHD survivors, suggesting that a larger sample of NH blacks would likely demonstrate further disparities. In addition to the small sample size for NH black CHD survivors, even smaller sample sizes were available for CHD survivors of other ethnicities and races, which reduced the focus of the current investigation to only NH blacks.
Our findings identify an underserved population in need of focused research and intervention. Adult CHD survivors have obesity rates similar to the general population. Compared with NH white CHD survivors, NH black CHD survivors are at a greater risk for obesity after adolescence, with more than half of adult NH blacks with CHD meeting obesity criteria. Monitoring of upward trends in body weight by healthcare providers, in conjunction with referrals for intervention, may prevent the cardiovascular comorbidities shortening the lifespans of these survivors. Obesity may be an important contributor to racial disparities in morbidity and mortality for nonwhite CHD survivors. Prospective research is needed to track obesity-related causes of morbidity and mortality, with special attention paid to adequately representing racial and ethnic minorities and with the ultimate goal of improving long-term outcomes for all CHD survivors.
- Non-Hispanic black CHD survivors have an elevated risk for obesity, which may be the driver of worst outcomes for this understudied population.
- Body weight for CHD survivors, particularly NH white and black children, as well as non-Hispanic black adults, should be monitored by healthcare professionals and referrals should be made for intervention, when appropriate, to prevent cardiovascular comorbidities.
1. Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease
: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease
2. Roche SL, Silversides CK. Hypertension, obesity
, and coronary artery disease in the survivors of congenital heart disease
. Can J Cardiol
3. Deen JF, Krieger EV, Slee AE, et al. Metabolic syndrome in adults with congenital heart disease
. J Am Heart Assoc
4. Lerman JB, Parness IA, Shenoy RU. Body weights in adults with congenital heart disease
and the obesity
frequency. Am J Cardiol
5. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity
and trends in body mass index among US children and adolescents, 1999–2010. JAMA
6. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity
and trends in the distribution of body mass index among US adults, 1999–2010. JAMA
7. Gilboa SM, Salemi JL, Nembhard WN, Fixler DE, Correa A. Mortality resulting from congenital heart disease
among children and adults in the United States, 1999 to 2006. Circulation
8. Gilboa SM, Devine OJ, Kucik JE, et al. Congenital heart defects in the United States: estimating the magnitude of the affected population in 2010. Circulation
9. Ogden CL, Flegal KM. Changes in terminology for childhood overweight and obesity
. Natl Health Stat Report
11. Barbiero SM, D’Azevedo SC, Schuh DS, Cesa CC, de Oliveira PR, Pellanda LC. Overweight and obesity
in children with congenital heart disease
: combination of risks for the future? BMC Pediatr
12. Agarwal S, Sud K, Khera S, et al. Trends in the burden of adult congenital heart disease
in US emergency departments. Clin Cardiol
13. Guerri-Guttenberg RA, Castilla R, Francos GC, Müller A, Ambrosio G, Milei J. Transforming growth factor β1 and coronary intimal hyperplasia in pediatric patients with congenital heart disease
. Can J Cardiol
14. Longmuir PE, Brothers JA, de Ferranti SD, et al. Promotion of physical activity for children and adults with congenital heart disease
: a scientific statement from the American Heart Association. Circulation
15. Longmuir PE, McCrindle BW. Physical activity restrictions for children after the Fontan operation: disagreement between parent, cardiologist, and medical record reports. Am Heart J
16. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation
17. Goode RW, Styn MA, Mendez DD, Gary-Webb TL. African Americans in standard behavioral treatment for obesity
, 2001–2015: what have we learned? West J Nurs Res
18. Chung ST, Hong B, Patterson L, Petit CJ, Ham JN. High overweight and obesity
in Fontan patients: a 20-year history. Pediatr Cardiol
19. Jackson JL, Hassen L, Gerardo GM, Vannatta K, Daniels CJ. Medical factors that predict quality of life for young adults with congenital heart disease
: what matters most? Int J Cardiol
20. Moons P, Van Deyk K, De Geest S, Gewillig M, Budts W. Is the severity of congenital heart disease
associated with the quality of life and perceived health of adult patients? Heart