What Nature Used to Allow to Die, Don't Let Modern Habits Damage After Repair: Preventable Obesity Risk in Congenital Heart Disease

Abstract

Despite universal warnings from health authorities, obesity has now reached epidemic proportion, not only in the developing countries (the poorer), but also in our most vulnerable patients.1World Health Organization Global Status Report on Noncommunicable Diseases 2010. World Health Organisation, Geneva, Switzerland2011Google Scholar, 2Pinto N.M. Marino B.S. Wernovsky G. et al.Obesity is a common comorbidity in children with congenital and acquired heart disease.Pediatrics. 2007; 120: e1157-e1164Crossref PubMed Scopus (145) Google Scholar Obesity has changed the practice of pediatric subspecialists. Indeed, pediatricians who specialize in endocrinology and in cardiology are now confronted with type 2 diabetes and cardiovascular risk factors management, respectively. Obesity is a common comorbidity in children with congenital and acquired heart disease.2Pinto N.M. Marino B.S. Wernovsky G. et al.Obesity is a common comorbidity in children with congenital and acquired heart disease.Pediatrics. 2007; 120: e1157-e1164Crossref PubMed Scopus (145) Google Scholar As cardiovascular heart defects management get better, using high-skilled surgical techniques and less invasive cardiovascular procedures, not only the survival rates improve, but also new health concerns have emerged among this population and might substantially reduce long-term prognosis.3Boneva R.S. Botto L.D. Moore C.A. et al.Mortality associated with congenital heart defects in the United States: trends and racial disparities, 1979-1997.Circulation. 2001; 103: 2376-2381Crossref PubMed Scopus (428) Google Scholar In this issue of the Canadian Journal of Cardiology, is a retrospective study by Tamayo et al.4Tamayo C. Manlhiot C. Patterson K. Lalani S. McCrindle B.W. Longitudinal evaluation of the prevalence of overweight/obesity in children with congenital heart disease.Can J Cardiol. 2015; 31: 117-123Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar on changes in anthropometric values among patients with cardiovascular heart defects and their capacity to exercise. Charts of patients who were managed at The Hospital for Sick Children, Toronto, Ontario between 1995 and 2005 were reviewed. Patients were eligible for the study if they had 1 of the following 6 diagnoses: (1) isolated atrial septal defect (ASD); (2) ventricular septal defect (VSD); (3) atrioventricular septal defect (AVSD); (4) tetralogy of Fallot/double outlet right ventricle (TOF/DORV); (5) transposition of the great arteries (TGA); or (6) single ventricle anatomy amenable to Fontan procedure. Medical records were randomly sampled. A random sampling strategy was used to select a representative subset of the eligible patient population (20%-22% in larger patient populations: ASD, TOF/DORV, VSD, and 30%-35% in smaller patient populations: AVSD, TGA, Fontan). Serial measurements of weight and height were abstracted and body mass index (BMI) was calculated. Patients with BMI ≥ 85th but < 95th percentile were classified as overweight, and those with BMI ≥ 95th percentile were classified as obese. Of included patients, 56% were male, 14% had Down syndrome; cardiac diagnosis distribution was: ASD, 18%; VSD, 21%; AVSD, 16%; TGA, 21%; TOF/DORV, 18%; and Fontan, 10%. Median follow-up from diagnosis for the 725 included patients was 7.1 years. Median age at the time of complete repair was 0.6 years (interquartile range, birth to 9.6 years); 86 patients (12%) had at least 1 palliative surgery before complete repair, and 18 patients (3%) had at least 1 surgery after full repair. Using BMI percentile cutoffs, 28% of patients had at least 1 BMI measurement indicating overweight and 17% indicating obesity. The presence of musculoskeletal anomalies or physical activity restrictions was not significantly associated with weight, height, or BMI over time. Available exercise test results in 153 patients showed that overweight/obese patients had a 16% lower predicted maximum oxygen consumption (P < 0.001), higher peak systolic blood pressure (11 mm Hg; P = 0.002), and higher systolic blood pressure response (7 mm Hg; P = 0.01) than normal weight patients. The mean age at exercise testing was 12.5 years. This study demonstrated that patients with congenital heart disease had a significant risk of being overweight/obese over time, a risk that is comparable with that observed in the general young population (approximately 30% overweight and 15% obese). Patients who underwent exercise testing as clinically indicated demonstrated that overweight/obese patients had lower exercise capacity and higher blood pressure response, which might contribute as an additional cardiovascular risk factor in the future. These data are of importance because it demonstrates that not only the presence of a cardiovascular disease additional risk factor among patients with cardiovascular heart defects, but shows for the first time a potential detrimental effect on youth heart's structure and function, which could contribute to the reduced exercise capacity in patients with obesity as an additional risk factor.Genetics is one of the major determinants of obesity, with heritability as high as 70%.5Xia Q. Grant S.F. The genetics of human obesity.Ann N Y Acad Sci. 2013; 1281: 178-190Crossref PubMed Scopus (120) Google Scholar, 6Zhao J. Grant S. Genetics of childhood obesity.J Obes. 2011; 2011: 845148Crossref PubMed Scopus (42) Google Scholar However, the presence of a surrounding toxic environment, mainly physical inactivity and poorer diets, has negative effects on cardiovascular health. This is preventable. Recent data have shown comparable prevalence (29%) of overweight and obesity in patients with cardiovascular heart defects in the National Health and Nutrition Examination Survey (NHANES) in the United States.2Pinto N.M. Marino B.S. Wernovsky G. et al.Obesity is a common comorbidity in children with congenital and acquired heart disease.Pediatrics. 2007; 120: e1157-e1164Crossref PubMed Scopus (145) Google Scholar Only the patients with Fontan procedures have shown a lowest prevalence (16%) of overweight and obesity.7Cohen M.S. Zak V. Atz A.M. et al.Anthropometric measures after Fontan procedure: implications for suboptimal functional outcome.Am Heart J. 2010; 160: 1092-1098Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar This later might be attributable to the growth restriction found in this subgroup, facing higher energy expenditure requirements. Growing as an adult, more than 1 of 2 (54%) youths with cardiovascular heart defects will present a BMI of ≥ 25.8Armstrong B.E. Heart disease in childhood: from malformed hearts to the silent impact of unhealthy lifestyles.N C Med J. 2012; 73: 490-493PubMed Google Scholar Pediatric obesity was previously reported to be associated with the presence of hypertension, concentric cardiac hypertrophy, left ventricular diastolic dysfunction, and carotid intima-media thickness.9St-Pierre J. Bouchard L. Poirier P. The impact of obesity on cardiovascular structure and function: the fetal programming era. Pediatric Health.Medicine and Therapeutics. 2012; 3: 1-8Crossref Google Scholar, 10Woo K.S. Chook P. Yu C.W. et al.Overweight in children is associated with arterial endothelial dysfunction and intima-media thickening.Int J Obes Relat Metab Disord. 2004; 28: 852-857Crossref PubMed Scopus (259) Google Scholar Specific corrected cardiovascular heart defects in patient with congenital heart disease might not be well tolerated or might deteriorate more rapidly in the presence of these additional cardiovascular risk factors. Obesity also predisposes young individuals to obstructive sleep apnea syndrome, lipid disorders, type 2 diabetes, orthopaedic problems, metabolic syndrome, hypertension, depression, and eventually to cerebrovascular and cardiovascular events.11Bray G.A. Medical consequences of obesity.J Clin Endocrinol Metab. 2004; 89: 2583-2589Crossref PubMed Scopus (1112) Google Scholar Even if the risk of developing obesity in patients with congenital heart defects is comparable to that of the general young population, those detrimental effects in addition to a repaired heart might have dramatic consequences over time.For a long time, the misperception of exercise being not well tolerated among those individuals has raised the myth of these individuals being more fragile and to restrict its practice.12Brassard P. Poirier P. Martin J. et al.Impact of exercise training on muscle function and ergoreflex in Fontan patients: a pilot study.Int J Cardiol. 2006; 107: 85-94Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Thereby, patients with cardiovascular heart defects have been restricted in physical activity and somehow overprotected by their parents, caregivers, and educators.13McCrindle B.W. Williams R.V. Mital S. et al.Physical activity levels in children and adolescents are reduced after the Fontan procedure, independent of exercise capacity, and are associated with lower perceived general health.Arch Dis Child. 2007; 92: 509-514Crossref PubMed Scopus (149) Google Scholar, 14Muller J. Christov F. Schreiber C. Hess J. Hager A. Exercise capacity, quality of life, and daily activity in the long-term follow-up of patients with univentricular heart and total cavopulmonary connection.Eur Heart J. 2009; 30: 2915-2920Crossref PubMed Scopus (100) Google Scholar Overprotection increases anxiety and decreases quality of life, which is already present in this population.15Knowles R.L. Bull C. Long-term survival and health outcomes for children living with congenital heart defects.Paediatr Child Health. 2013; 23: 73-77Abstract Full Text Full Text PDF Scopus (2) Google Scholar Moreover, children with cardiovascular heart defects are more likely (relative risk; RR) to become overweight (RR, 2.5) or obese (RR, 6.1).16Stefan M.A. Hopman W.M. Smythe J.F. Effect of activity restriction owing to heart disease on obesity.Arch Pediatr Adolesc Med. 2005; 159: 477-481Crossref PubMed Scopus (79) Google Scholar Obesity in youths has psychological consequences on mental health, self-esteem, body image, and health-related quality of life. Restricting physical activity in the cardiovascular heart defects population could potentially harm even more.17Nieman P. Leblanc C.M. Psychosocial aspects of child and adolescent obesity.Paediatr Child Health. 2012; 17: 205-208PubMed Google Scholar Physical activity recommendations and grades of recommendations for common congenital heart defects have been reviewed and published.18Takken T. Giardini A. Reybrouck T. et al.Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology.Eur J Prev Cardiol. 2012; 19: 1034-1065Crossref PubMed Scopus (157) Google Scholar Exercise capacity is an important predictor of morbidity and survival in patients with cardiovascular disease.19Myers J. Prakash M. Froelicher V. et al.Exercise capacity and mortality among men referred for exercise testing.N Engl J Med. 2002; 346: 793-801Crossref PubMed Scopus (2814) Google Scholar, 20Gulati M. Black H.R. Shaw L.J. et al.The prognostic value of a nomogram for exercise capacity in women.N Engl J Med. 2005; 353: 468-475Crossref PubMed Scopus (311) Google Scholar Parents of children with cardiovascular heart defects, and youth and teenagers with cardiovascular heart defects should be referred to a specialized cardiopulmonary rehabilitation centre to receive appropriate recommendations and adequate exercise prescription related to the specific corrected cardiovascular heart defects if needed.18Takken T. Giardini A. Reybrouck T. et al.Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology.Eur J Prev Cardiol. 2012; 19: 1034-1065Crossref PubMed Scopus (157) Google Scholar However, the 2012 recommendations for physical activity, recreation sport, and exercise training can be discussed over the phone with the patient's pediatric cardiologist, if not accessible.18Takken T. Giardini A. Reybrouck T. et al.Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology.Eur J Prev Cardiol. 2012; 19: 1034-1065Crossref PubMed Scopus (157) Google Scholar Clinicians should also advise patients with cardiovascular heart defects on healthy living, including tobacco use cessation, Canada's Food Guide, sleep recommendations, and remind parents to limit screen time (TV, gaming, computer, and portable device) to < 2 hours daily.21Pemberton V.L. McCrindle B.W. Barkin S. et al.Report of the National Heart, Lung, and Blood Institute's Working Group on obesity and other cardiovascular risk factors in congenital heart disease.Circulation. 2010; 121: 1153-1159Crossref PubMed Scopus (85) Google ScholarThe epidemic of obesity requires joint efforts from all health care professionals to reduce its prevalence. We must encourage physical activity and rehabilitation in patients with cardiovascular heart defects as soon as the defect is corrected or palliated.16Stefan M.A. Hopman W.M. Smythe J.F. Effect of activity restriction owing to heart disease on obesity.Arch Pediatr Adolesc Med. 2005; 159: 477-481Crossref PubMed Scopus (79) Google Scholar, 22Thompson P.D. Buchner D. Pina I.L. et al.Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity).Circulation. 2003; 107: 3109-3116Crossref PubMed Scopus (1557) Google Scholar, 23Moola F. McCrindle B.W. Longmuir P.E. Physical activity participation in youth with surgically corrected congenital heart disease: devising guidelines so Johnny can participate.Paediatr Child Health. 2009; 14: 167-170PubMed Google Scholar The combination of motivational interviewing, nutritional and physical education, and a close follow-up in a multidisciplinary setting, was previously shown to be effective to initiate and sustain beneficial lifestyle changes at 6 months and 1 year in obese children. This combined familial approach appears promising to reduce obesity prevalence in adolescents.24St-Pierre J. Thibault C. Harvey J. et al.How to successfully manage adolescents’ metabolic syndrome.Keep it simple! Circulation. 2013; 127: P250Google Scholar In addition, community-based programs to reduce childhood obesity (such as the American Let's Move! program by Michelle Obama)25White House Task Force on Childhood Obesity Report to the President. White House, Washington, DC2010Google Scholar or the World Health Organization recommendations26World Health Organization Population-based approaches to childhood obesity prevention. World Health Organisation, Geneva, Switzerland2012Google Scholar are available online for free consultation and can be used to develop population preventive strategies and inculcate healthy living among those young individuals. Of course, longitudinal prospective studies are still required to determine the real long-term effect of obesity in patients with repaired cardiovascular heart defects. However, we, as a society, have encouraged and paid for medical care in this population for years, and have supported pediatric cardiologists and cardiac surgeons to improve surgical techniques and management in these patients. So, why are we, as a society, letting our environment destroy what we have protected and cared for so long; not only patients with cardiovascular heart defects, but also our children and our future? This is the time for pediatric cardiologists to tackle this contemporary version of Charlie Chaplin's Modern Times movie.DisclosuresThe authors have no conflicts of interest to disclose. Despite universal warnings from health authorities, obesity has now reached epidemic proportion, not only in the developing countries (the poorer), but also in our most vulnerable patients.1World Health Organization Global Status Report on Noncommunicable Diseases 2010. World Health Organisation, Geneva, Switzerland2011Google Scholar, 2Pinto N.M. Marino B.S. Wernovsky G. et al.Obesity is a common comorbidity in children with congenital and acquired heart disease.Pediatrics. 2007; 120: e1157-e1164Crossref PubMed Scopus (145) Google Scholar Obesity has changed the practice of pediatric subspecialists. Indeed, pediatricians who specialize in endocrinology and in cardiology are now confronted with type 2 diabetes and cardiovascular risk factors management, respectively. Obesity is a common comorbidity in children with congenital and acquired heart disease.2Pinto N.M. Marino B.S. Wernovsky G. et al.Obesity is a common comorbidity in children with congenital and acquired heart disease.Pediatrics. 2007; 120: e1157-e1164Crossref PubMed Scopus (145) Google Scholar As cardiovascular heart defects management get better, using high-skilled surgical techniques and less invasive cardiovascular procedures, not only the survival rates improve, but also new health concerns have emerged among this population and might substantially reduce long-term prognosis.3Boneva R.S. Botto L.D. Moore C.A. et al.Mortality associated with congenital heart defects in the United States: trends and racial disparities, 1979-1997.Circulation. 2001; 103: 2376-2381Crossref PubMed Scopus (428) Google Scholar In this issue of the Canadian Journal of Cardiology, is a retrospective study by Tamayo et al.4Tamayo C. Manlhiot C. Patterson K. Lalani S. McCrindle B.W. Longitudinal evaluation of the prevalence of overweight/obesity in children with congenital heart disease.Can J Cardiol. 2015; 31: 117-123Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar on changes in anthropometric values among patients with cardiovascular heart defects and their capacity to exercise. Charts of patients who were managed at The Hospital for Sick Children, Toronto, Ontario between 1995 and 2005 were reviewed. Patients were eligible for the study if they had 1 of the following 6 diagnoses: (1) isolated atrial septal defect (ASD); (2) ventricular septal defect (VSD); (3) atrioventricular septal defect (AVSD); (4) tetralogy of Fallot/double outlet right ventricle (TOF/DORV); (5) transposition of the great arteries (TGA); or (6) single ventricle anatomy amenable to Fontan procedure. Medical records were randomly sampled. A random sampling strategy was used to select a representative subset of the eligible patient population (20%-22% in larger patient populations: ASD, TOF/DORV, VSD, and 30%-35% in smaller patient populations: AVSD, TGA, Fontan). Serial measurements of weight and height were abstracted and body mass index (BMI) was calculated. Patients with BMI ≥ 85th but < 95th percentile were classified as overweight, and those with BMI ≥ 95th percentile were classified as obese. Of included patients, 56% were male, 14% had Down syndrome; cardiac diagnosis distribution was: ASD, 18%; VSD, 21%; AVSD, 16%; TGA, 21%; TOF/DORV, 18%; and Fontan, 10%. Median follow-up from diagnosis for the 725 included patients was 7.1 years. Median age at the time of complete repair was 0.6 years (interquartile range, birth to 9.6 years); 86 patients (12%) had at least 1 palliative surgery before complete repair, and 18 patients (3%) had at least 1 surgery after full repair. Using BMI percentile cutoffs, 28% of patients had at least 1 BMI measurement indicating overweight and 17% indicating obesity. The presence of musculoskeletal anomalies or physical activity restrictions was not significantly associated with weight, height, or BMI over time. Available exercise test results in 153 patients showed that overweight/obese patients had a 16% lower predicted maximum oxygen consumption (P < 0.001), higher peak systolic blood pressure (11 mm Hg; P = 0.002), and higher systolic blood pressure response (7 mm Hg; P = 0.01) than normal weight patients. The mean age at exercise testing was 12.5 years. This study demonstrated that patients with congenital heart disease had a significant risk of being overweight/obese over time, a risk that is comparable with that observed in the general young population (approximately 30% overweight and 15% obese). Patients who underwent exercise testing as clinically indicated demonstrated that overweight/obese patients had lower exercise capacity and higher blood pressure response, which might contribute as an additional cardiovascular risk factor in the future. These data are of importance because it demonstrates that not only the presence of a cardiovascular disease additional risk factor among patients with cardiovascular heart defects, but shows for the first time a potential detrimental effect on youth heart's structure and function, which could contribute to the reduced exercise capacity in patients with obesity as an additional risk factor. Genetics is one of the major determinants of obesity, with heritability as high as 70%.5Xia Q. Grant S.F. The genetics of human obesity.Ann N Y Acad Sci. 2013; 1281: 178-190Crossref PubMed Scopus (120) Google Scholar, 6Zhao J. Grant S. Genetics of childhood obesity.J Obes. 2011; 2011: 845148Crossref PubMed Scopus (42) Google Scholar However, the presence of a surrounding toxic environment, mainly physical inactivity and poorer diets, has negative effects on cardiovascular health. This is preventable. Recent data have shown comparable prevalence (29%) of overweight and obesity in patients with cardiovascular heart defects in the National Health and Nutrition Examination Survey (NHANES) in the United States.2Pinto N.M. Marino B.S. Wernovsky G. et al.Obesity is a common comorbidity in children with congenital and acquired heart disease.Pediatrics. 2007; 120: e1157-e1164Crossref PubMed Scopus (145) Google Scholar Only the patients with Fontan procedures have shown a lowest prevalence (16%) of overweight and obesity.7Cohen M.S. Zak V. Atz A.M. et al.Anthropometric measures after Fontan procedure: implications for suboptimal functional outcome.Am Heart J. 2010; 160: 1092-1098Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar This later might be attributable to the growth restriction found in this subgroup, facing higher energy expenditure requirements. Growing as an adult, more than 1 of 2 (54%) youths with cardiovascular heart defects will present a BMI of ≥ 25.8Armstrong B.E. Heart disease in childhood: from malformed hearts to the silent impact of unhealthy lifestyles.N C Med J. 2012; 73: 490-493PubMed Google Scholar Pediatric obesity was previously reported to be associated with the presence of hypertension, concentric cardiac hypertrophy, left ventricular diastolic dysfunction, and carotid intima-media thickness.9St-Pierre J. Bouchard L. Poirier P. The impact of obesity on cardiovascular structure and function: the fetal programming era. Pediatric Health.Medicine and Therapeutics. 2012; 3: 1-8Crossref Google Scholar, 10Woo K.S. Chook P. Yu C.W. et al.Overweight in children is associated with arterial endothelial dysfunction and intima-media thickening.Int J Obes Relat Metab Disord. 2004; 28: 852-857Crossref PubMed Scopus (259) Google Scholar Specific corrected cardiovascular heart defects in patient with congenital heart disease might not be well tolerated or might deteriorate more rapidly in the presence of these additional cardiovascular risk factors. Obesity also predisposes young individuals to obstructive sleep apnea syndrome, lipid disorders, type 2 diabetes, orthopaedic problems, metabolic syndrome, hypertension, depression, and eventually to cerebrovascular and cardiovascular events.11Bray G.A. Medical consequences of obesity.J Clin Endocrinol Metab. 2004; 89: 2583-2589Crossref PubMed Scopus (1112) Google Scholar Even if the risk of developing obesity in patients with congenital heart defects is comparable to that of the general young population, those detrimental effects in addition to a repaired heart might have dramatic consequences over time. For a long time, the misperception of exercise being not well tolerated among those individuals has raised the myth of these individuals being more fragile and to restrict its practice.12Brassard P. Poirier P. Martin J. et al.Impact of exercise training on muscle function and ergoreflex in Fontan patients: a pilot study.Int J Cardiol. 2006; 107: 85-94Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Thereby, patients with cardiovascular heart defects have been restricted in physical activity and somehow overprotected by their parents, caregivers, and educators.13McCrindle B.W. Williams R.V. Mital S. et al.Physical activity levels in children and adolescents are reduced after the Fontan procedure, independent of exercise capacity, and are associated with lower perceived general health.Arch Dis Child. 2007; 92: 509-514Crossref PubMed Scopus (149) Google Scholar, 14Muller J. Christov F. Schreiber C. Hess J. Hager A. Exercise capacity, quality of life, and daily activity in the long-term follow-up of patients with univentricular heart and total cavopulmonary connection.Eur Heart J. 2009; 30: 2915-2920Crossref PubMed Scopus (100) Google Scholar Overprotection increases anxiety and decreases quality of life, which is already present in this population.15Knowles R.L. Bull C. Long-term survival and health outcomes for children living with congenital heart defects.Paediatr Child Health. 2013; 23: 73-77Abstract Full Text Full Text PDF Scopus (2) Google Scholar Moreover, children with cardiovascular heart defects are more likely (relative risk; RR) to become overweight (RR, 2.5) or obese (RR, 6.1).16Stefan M.A. Hopman W.M. Smythe J.F. Effect of activity restriction owing to heart disease on obesity.Arch Pediatr Adolesc Med. 2005; 159: 477-481Crossref PubMed Scopus (79) Google Scholar Obesity in youths has psychological consequences on mental health, self-esteem, body image, and health-related quality of life. Restricting physical activity in the cardiovascular heart defects population could potentially harm even more.17Nieman P. Leblanc C.M. Psychosocial aspects of child and adolescent obesity.Paediatr Child Health. 2012; 17: 205-208PubMed Google Scholar Physical activity recommendations and grades of recommendations for common congenital heart defects have been reviewed and published.18Takken T. Giardini A. Reybrouck T. et al.Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology.Eur J Prev Cardiol. 2012; 19: 1034-1065Crossref PubMed Scopus (157) Google Scholar Exercise capacity is an important predictor of morbidity and survival in patients with cardiovascular disease.19Myers J. Prakash M. Froelicher V. et al.Exercise capacity and mortality among men referred for exercise testing.N Engl J Med. 2002; 346: 793-801Crossref PubMed Scopus (2814) Google Scholar, 20Gulati M. Black H.R. Shaw L.J. et al.The prognostic value of a nomogram for exercise capacity in women.N Engl J Med. 2005; 353: 468-475Crossref PubMed Scopus (311) Google Scholar Parents of children with cardiovascular heart defects, and youth and teenagers with cardiovascular heart defects should be referred to a specialized cardiopulmonary rehabilitation centre to receive appropriate recommendations and adequate exercise prescription related to the specific corrected cardiovascular heart defects if needed.18Takken T. Giardini A. Reybrouck T. et al.Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology.Eur J Prev Cardiol. 2012; 19: 1034-1065Crossref PubMed Scopus (157) Google Scholar However, the 2012 recommendations for physical activity, recreation sport, and exercise training can be discussed over the phone with the patient's pediatric cardiologist, if not accessible.18Takken T. Giardini A. Reybrouck T. et al.Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology.Eur J Prev Cardiol. 2012; 19: 1034-1065Crossref PubMed Scopus (157) Google Scholar Clinicians should also advise patients with cardiovascular heart defects on healthy living, including tobacco use cessation, Canada's Food Guide, sleep recommendations, and remind parents to limit screen time (TV, gaming, computer, and portable device) to < 2 hours daily.21Pemberton V.L. McCrindle B.W. Barkin S. et al.Report of the National Heart, Lung, and Blood Institute's Working Group on obesity and other cardiovascular risk factors in congenital heart disease.Circulation. 2010; 121: 1153-1159Crossref PubMed Scopus (85) Google Scholar The epidemic of obesity requires joint efforts from all health care professionals to reduce its prevalence. We must encourage physical activity and rehabilitation in patients with cardiovascular heart defects as soon as the defect is corrected or palliated.16Stefan M.A. Hopman W.M. Smythe J.F. Effect of activity restriction owing to heart disease on obesity.Arch Pediatr Adolesc Med. 2005; 159: 477-481Crossref PubMed Scopus (79) Google Scholar, 22Thompson P.D. Buchner D. Pina I.L. et al.Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity).Circulation. 2003; 107: 3109-3116Crossref PubMed Scopus (1557) Google Scholar, 23Moola F. McCrindle B.W. Longmuir P.E. Physical activity participation in youth with surgically corrected congenital heart disease: devising guidelines so Johnny can participate.Paediatr Child Health. 2009; 14: 167-170PubMed Google Scholar The combination of motivational interviewing, nutritional and physical education, and a close follow-up in a multidisciplinary setting, was previously shown to be effective to initiate and sustain beneficial lifestyle changes at 6 months and 1 year in obese children. This combined familial approach appears promising to reduce obesity prevalence in adolescents.24St-Pierre J. Thibault C. Harvey J. et al.How to successfully manage adolescents’ metabolic syndrome.Keep it simple! Circulation. 2013; 127: P250Google Scholar In addition, community-based programs to reduce childhood obesity (such as the American Let's Move! program by Michelle Obama)25White House Task Force on Childhood Obesity Report to the President. White House, Washington, DC2010Google Scholar or the World Health Organization recommendations26World Health Organization Population-based approaches to childhood obesity prevention. World Health Organisation, Geneva, Switzerland2012Google Scholar are available online for free consultation and can be used to develop population preventive strategies and inculcate healthy living among those young individuals. Of course, longitudinal prospective studies are still required to determine the real long-term effect of obesity in patients with repaired cardiovascular heart defects. However, we, as a society, have encouraged and paid for medical care in this population for years, and have supported pediatric cardiologists and cardiac surgeons to improve surgical techniques and management in these patients. So, why are we, as a society, letting our environment destroy what we have protected and cared for so long; not only patients with cardiovascular heart defects, but also our children and our future? This is the time for pediatric cardiologists to tackle this contemporary version of Charlie Chaplin's Modern Times movie. DisclosuresThe authors have no conflicts of interest to disclose. The authors have no conflicts of interest to disclose.