#ResearchRecap – Good Health Behaviors in Adults with CHD

Oct 7, 2019 | Brianna N. Tranby | @briannatranby

HLHS blog - health behaviors


Good health behaviors are defined as “actions that individuals take to maintain or enhance their health and reduce health risks” and are especially important for individuals with congenital heart disease (CHD), including hypoplastic left heart syndrome (HLHS).  But how likely are adults with CHD to actually maintain a heart-healthy lifestyle?  This week’s #ResearchRecap reviews an important and insightful study that aimed to answer that question.  (4 minute read)

Health behaviors reported by adults with congenital heart disease across 15 countries.
Holbein, et al., September 17, 2019
European Journal of Preventive Cardiology https://journals.sagepub.com/doi/full/10.1177/2047487319876231


Little is known about the details of important health behaviors in adults with CHD, and even less is known about these behaviors in countries around the world. Researchers in Belgium coordinated an extensive international study to start answering these questions. The study enrolled 4,028 patients in 15 countries on five continents: 2 in North America, 1 in South America, 8 in Europe, 3 in Asia, and Australia. The average age of participants was 32, 53% were women, and half had at least moderate CHD.

Participants completed several surveys and had their medical records reviewed. All data was collected from April 2013-March 2015. Patients were eligible to enroll if they were over 18, had been diagnosed with CHD before adolescence, and had not undergone a heart transplant. The study had three aims:

  1. Describe health behaviors in a large international sample of adults with CHD.
  2. Compare health behaviors in this sample across countries.
  3. Identify patient characteristic associated with health behaviors.


Description of Health Behaviors

Seven health behaviors were studied: binge drinking, cigarette smoking, recreational drug use, visiting the dentist at least once a year, brushing their teeth twice a day, flossing once a day, and regular physical activity. Patients were also asked to report their level of “functional status” using the New York Heart Association (NYHA) classes of heart failure ranging from Class I (no limitation of physical activity) to Class IV (unable to carry on physical activity without discomfort).

hb chart

The authors note that these findings are in line with previous research which suggests that “the health behaviors of adults with CHD may largely follow trends of the general population, with the presence of CHD having only a subtle impact.” Yet, they also point out that good health behaviors are especially important for adults with CHD given that “they are at higher risk than the general population for cardiovascular events.”


Comparison across Countries

Consistent with general population trends, adults with CHD reported higher rates of smoking and binge drinking in Australia and several Western and Northern Europe countries. Recreational drug use (e.g., cannabis, ‘ecstasy’, ‘speed’, ‘mushrooms’, cocaine) was highest in North and South America, while patients from India and Taiwan reported the lowest levels of substance use.

Western and Northern European countries had the highest rates of annual dental visits (84%), while India was the lowest (28%). Brushing and flossing varied widely across all countries; 64% of patients in the United States reported brushing twice a day and 33% reported flossing daily. For physical activity, the US and Asia reported the lowest rates of regular physical activity, while higher rates were seen in Western and Northern Europe.

It’s important to keep in mind that there are many reasons for differences in the rates of certain health behaviors across countries. The authors note that factors such as national level of development, cultural values, laws, and geographic barriers may result in patients being more or less likely to engage in certain behaviors. For example, personal use of cannabis is legal in several countries studied here, while other researchers have reported that most people in India don’t have access to basic dental care (Gambhir et al., 2013).


Individuals and Health Behaviors

For their third aim, the researchers correlated the seven health behaviors with demographics including age, sex, marital/cohabiting status, education level, defect complexity, and functional status. Patients who were younger, male, less educated, and had less complex CHDs were more likely to report binge drinking and smoking. Recreational drug use was more often reported by people who had worse functional status, were unemployed, and unmarried.

Remember: In studies like this, “correlation does not imply causation.” This means that we don’t know if being unemployed, unmarried, and having worse functional status causes someone to use recreational drugs, or if using drugs causes someone to have these characteristics. In this study, they were reported together more often, but there may be other causes that were not explored.

All three aspects of dental care were correlated with older age, higher education, and being female. Patients were less likely to report regular brushing and flossing if they had a worse functional status. This is especially concerning given that “CHD patients are at greater risk for cardiovascular complications including endocarditis (infection in the heart valves or lining of the interior surfaces of the heart)… and that dental problems are a leading cause of infective endocarditis.”

Participants in this study who reported regular physical activity were more often younger, male, employed/students, had higher education, less complex defects, and better functional status. The authors note that physicians have historically been reluctant to encourage physical activity in complex CHD patients. However, new research has shown that appropriate exercise and cardiac rehab can be beneficial for people with severe defects.


While many adults with CHD maintain a heart-healthy lifestyle, there are still areas for improvement that vary in specific areas across countries and individuals. This study provides important information for both medical providers and for the future development of programs to assess, educate, and improve access to good health behaviors for adults with CHD.


Meet other people talking about HLHS or CHD on Mayo Clinic Connect – an online community designed to help patients and families connect with each other.  Our community is a safe space to share experiences, ask questions, find answers, and exchange support.  The discussion groups and topic pages are moderated to ensure that all posts are respectful, and Mayo Clinic Connect never sells or shares posted information to third parties.  Here are some you might like to follow:

The Todd and Karen Wanek Family Program for Hypoplastic Left Heart Syndrome (HLHS) is a collaborative network of specialists bonded by the vision of finding solutions for individuals affected by congenital heart defects including HLHS. Our specialized team is addressing the various aspects of these defects by using research and clinical strategies ranging from basic science to diagnostic imaging to regenerative therapies. Email us at HLHS@mayo.edu to learn more.

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