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Nutrition and weight

Low BMI is NOT ‘normal’ for those with OA/TOF and is a sign of poor nutrition as a result of difficulties eating and/or malabsorption.

Food intake can be an ongoing problem post OA/TOF repair. 

Multiple studies have shown that adults born with OA/TOF have lower BMIs, with one showing 24.3% had a BMI less than 18.5. (97) This can follow on from a childhood of poor nutrition, with growth stunting found in between 5% and 15% of adults. (94,95) Birketvedt et al. (94) found 71% of adolescents were eating less calories than the recommended calorie intake for their age and a third less than their basal metabolic rate. They posit two causes for this: dysphagia and severe postprandial fullness. Dysphagia leads to selective eating, avoiding foods like meat, bread and other foods which are difficult to swallow. Hyperalimentation (excessive drinking to expedite food down the oesophagus) and oesophageal stasis and gastroparesis lead to severe postprandial fullness with lower quantities of macronutrients consumed.

Malnutrition is related to surgical factors/type of OA – delayed primary anastomosis of long-gap OA, jejunostomy, gastric pull-up and pyloromyotomy all have a poorer prognosis for malnutrition. (96) However, poor growth and weight is commonest in early childhood, with catch up around age 8, so for many adults born with OA/TOF, any such issues will likely be historical. Nonetheless, none of the Adult TOFs in the study by Presse et al. were classified as ‘tall’, suggesting that whilst many TOFs reach a normal height, they may not reach their full height potential if they had not had OA/TOF. (96,97)

There is also low intake of micronutrients such as vitamin D, riboflavin, calcium and iron, as well as reduced intake of macronutrients, particularly carbohydrates. (94) Nutrition and weight are a particular issue for those with repaired long-gap OA/TOF. (31) Post gastric transposition, 47% of adults are anaemic, compared with 9% with primary repair, and 19% still need supplemental feeding.

Signs of malnutrition/wasting in OA/TOF patients:

  • Low BMI
  • Continued weight loss
  • Persistent inflammatory state
  • Failure to respond to adequate nutritional support

Issues to monitor

  • BMI/weight
  • Ask patient about eating/swallowing difficulties. Are they drinking more than usual for them to help food down? Have they had increasing issues with foods getting ‘stuck’?
  • Consider referral for indirect calorimetry measurement
  • Vitamin D levels
  • Haemoglobin/FBC, ferritin, consider iron saturation.
  • Magnesium, calcium, B12 levels if signs of deficiency
  • Assess for osteoporosis due to poor calcium and vitamin D absorption and long-term PPI use.

Recommended actions

  • Dietician input if nutritional status directs – this supportive care would also need referrals as below.
  • Upper GI surgeon referral/gastroenterology referral to investigate dysphagia, preferably one with experience in long-term effects of OA/TOF. (94,96)