Healthy Habits, Physical Activity, Stress, and Food Consumption Trends in Chilean Adults with Irritable Bowel Syndrome during the COVID-19 Pandemic

Round 1

Reviewer 1 Report

Thank you for the opportunity to review your paper, titled: “Healthy habits, physical activity, stress, and food consumption 2 trends in Chilean adults with irritable bowel syndrome during 3 the COVID-19 pandemic.” This paper provides information on habits during the COVID 19 pandemic in a group of 34 individuals (IBS and controls) in Chile.  

Introduction: page 2, line 51-53

The paper states that the world is facing a pandemic/emergency now. This is not the height of the pandemic for many countries, and the statement might need to be revised. The pathophysiology of IBS needs to include current references. IBS is considered Disorder of Brain-Gut Interaction and this new terminology should be used. It is not clear Rome III criteria were used when the more current criteria Rome IV were available.

Introduction: page 2, line 62-65

Provide a reference.

2.2 Population and inclusion criteria:page 2

This part is confusing with the inclusion criteria. From what I gather, the inclusion criteria are adults without an inflammatory disease. There is no need to add the portions about “with or without abdominal pain,” “both genders,” and “engaging in physical activity or not.” Please provide examples of “disease indicating an inflammatory process.”

2.3 Instruments: page 3

Please provide how items are scored in these surveys, especially the lifestyle survey. We do not have access to the suppl.2. Is the lifestyle survey only based on meals/food/diet or does it include exercise, sleep, and other habits; also are all habits equally weighted on the survey?

2.4 Interviews, data collection, analysis: page 4, lines 152-154

Are the two groups being compared based on the lifestyle survey or the GPAQ? A major issue with the manuscript is the lack of clarity of what was done. What was the study design? In one place the authors state it was an exploratory study and yet the aim was ‘to assess’. The statistics seem to suggest that comparisons were made. Did the authors start with a hypothesis?

3. Results, page 4, lines 167

Does the lifestyle survey include items about physical activity? If so, would this be already expected?

3. Results, page 5, lines 181

What is considered a high level of stress? This is not clearly stated in the 2.3 instruments section with the DASS-21 Psychological Stress Survey or in results.

3. Results, page 5, lines 185

Based on Table 3, it seems that more controls consumed alcohol than IBS cases. Doesn’t this indicate that there are LESS individuals with IBS (7%) who drink compared to healthy controls? (50%) Potentially table 3 should have a different number for alcohol % for IBS cases?

Table 1, 2, 3: There are stars on items with p>0.05. This is very confusing for readers. Most of the time stars are only left for items that meet significance. You can state the t test and chi-squared tests in a separate column or as a comment.  Was there control for multiple comparisons?

Table 3: The number of IBS cases and controls combined is 54. This is not correct.

4.3 Main findings and clinical implications, page 7, lines 234-236

Please provide a reference for the hormonal factors playing a role in the gender disparity in IBS.

4.3 main findings and clinical implications, page 8, lines 273-285

This seems a bit irrelevant and unneeded

Author Response

Introduction: page 2, line 51-53

The paper states that the world is facing a pandemic/emergency now. This is not the height of the pandemic for many countries, and the statement might need to be revised. The pathophysiology of IBS needs to include current references. IBS is considered Disorder of Brain-Gut Interaction and this new terminology should be used. It is not clear Rome III criteria were used when the more current criteria Rome IV were available.

RESPONSE: It has been corrected.

Introduction: page 2, line 62-65. Provide a reference.

 RESPONSE: It has been added.

2.2 Population and inclusion criteria:page 2

This part is confusing with the inclusion criteria. From what I gather, the inclusion criteria are adults without an inflammatory disease. There is no need to add the portions about “with or without abdominal pain,” “both genders,” and “engaging in physical activity or not.” Please provide examples of “disease indicating an inflammatory process.”

RESPONSE: This section has been modified.

2.3 Instruments: page 3

Please provide how items are scored in these surveys, especially the lifestyle survey. We do not have access to the suppl.2. Is the lifestyle survey only based on meals/food/diet or does it include exercise, sleep, and other habits; also are all habits equally weighted on the survey?

RESPONSE: This section has been modified. The survey has been better described. The lifestyle survey is based solely on meals/foods/diet.

2.4 Interviews, data collection, analysis: page 4, lines 152-154

Are the two groups being compared based on the lifestyle survey or the GPAQ? A major issue with the manuscript is the lack of clarity of what was done. What was the study design? In one place the authors state it was an exploratory study and yet the aim was ‘to assess’. The statistics seem to suggest that comparisons were made. Did the authors start with a hypothesis?

RESPONSE: The hypothesis of the study has been described along with the objective. The type of study has been clarified. Both groups have been compared according to their dietary habits.

3. Results, page 4, lines 167

Does the lifestyle survey include items about physical activity? If so, would this be already expected?

 RESPONSE: Does not include those items.

3. Results, page 5, lines 181

What is considered a high level of stress? This is not clearly stated in the 2.3 instruments section with the DASS-21 Psychological Stress Survey or in results.

 RESPONSE: We explain what has been considered high stress.

3. Results, page 5, lines 185

Based on Table 3, it seems that more controls consumed alcohol than IBS cases. Doesn’t this indicate that there are LESS individuals with IBS (7%) who drink compared to healthy controls? (50%) Potentially table 3 should have a different number for alcohol % for IBS cases?

RESPONSE: The table has been corrected, the previous one had an error in the writing of that data.

 Table 1, 2, 3: There are stars on items with p>0.05. This is very confusing for readers. Most of the time stars are only left for items that meet significance. You can state the t test and chi-squared tests in a separate column or as a comment.  Was there control for multiple comparisons?

RESPONSE: This data has been simplified.

Table 3: The number of IBS cases and controls combined is 54. This is not correct.

 RESPONSE: The table has been corrected, the previous one had an error in the writing of that data.

4.3 Main findings and clinical implications, page 7, lines 234-236. Please provide a reference for the hormonal factors playing a role in the gender disparity in IBS.

 RESPONSE: A reference was added.

4.3 main findings and clinical implications, page 8, lines 273-285

This seems a bit irrelevant and unneeded

RESPONSE: We consider that this text contributes to contextualizing the issue of IBS in Latin America.

Reviewer 2 Report

Dear Athors,

The aim of this study is to explain how quarantine habits and lifestyles act as risk factors for the frequency of irritable bowel syndrome during the COVID-19 pandemic. The research hypothesis is based on a well-studied problem. The authors should analyze and present the novelty and significance of this study.

The study has a serious methodological flaw due to its small sample size. It was not noted how the sample size was calculated to ensure the validity of the studies being conducted. Since a cross-sectional study was used, the sample size of 34 is not sufficient to draw a conclusion. A sample size of at least 60 is generally recommended.

A cross-sectional study assesses the prevalence of factors and does not reveal causality due to unknown temporality.

The methodology should be stated more clearly. The study design must be clearly shown. Paragraph 2.1. does not represent the study design.

Data collection needs to be presented more clearly. Parameters should be mentioned. Thera are no Supplements available. Therefore, this aspect cannot be assessed.

My conclusion is that the article is not ready for publication, as it has serious flaws, the analysis of the data was not carried out correctly, and the study was not conducted correctly.

Author Response

The aim of this study is to explain how quarantine habits and lifestyles act as risk factors for the frequency of irritable bowel syndrome during the COVID-19 pandemic. The research hypothesis is based on a well-studied problem. The authors should analyze and present the novelty and significance of this study.

RESPONSE: The novelty of the paper has been improved

The study has a serious methodological flaw due to its small sample size. It was not noted how the sample size was calculated to ensure the validity of the studies being conducted. Since a cross-sectional study was used, the sample size of 34 is not sufficient to draw a conclusion. A sample size of at least 60 is generally recommended.

RESPONSE: We understand the limitation of sample size. We were NOT able to have more patients during the pandemic and through contacts. This has been included in the limitations section

A cross-sectional study assesses the prevalence of factors and does not reveal causality due to unknown temporality. The methodology should be stated more clearly. The study design must be clearly shown. Paragraph 2.1. does not represent the study design.

RESPONSE: This section has been modified.

Data collection needs to be presented more clearly. Parameters should be mentioned. Thera are no Supplements available. Therefore, this aspect cannot be assessed.

RESPONSE: This section has been modified. Please request supplementary materials from the editors.

Reviewer 3 Report

This study used multiple surveys and interviews to gather data to explain how quarantine habits and lifestyle factors could be risk factors in frequency of irritable bowel syndrome among Chilean participants.  This study is important and the abstract reads well; however, I have some recommendations for this paper that could improve it further:

1.     Regarding lines 86-87, key demographics about mortality from COVID-19 may be beneficial to the introduction section. 

2.     Please elaborate if a power analysis was conducted for the effect size, sample size, and statistical power? The sample size was low for surveys. 

3.     Lines 93-94 may need to be reworded as it currently states that inclusion criteria were engaging in physical activity or not (it could not be both so I think it should be “engaging in physical activity”.

4.     For section 2.3, what was the response rate for the surveys?

5.     Table 2 there are some acronyms that need to be written out first before they are written as SFA, MUFA and CHO.  Is CHO cholesterol? Tables 2 and 3 also have a spelling error and “Cafein” should be “Caffeine” and “Controles” should be “Control”

6.     Table 4 requires more info; was it logistic regression or linear regression? Line 154 lists both erroneously. What was r squared values? You should also indicate that the p-value was statistically significant at P<0.05 under the table. 

7.     The limitations section should certainly include the fact that the survey data used very small sample sizes.

8.     Methods – Was this a mixed-methods study? If yes, were the interviews recorded using Google Meet? It seems like the interviews were not really qualitative interviews but were rather meant to administer survey instruments – if that is the case, then perhaps rephrase this section to state this? Otherwise, more information is required. E.g. were interview transcripts generated? Were transcripts thematically analyzed? Were they coded? How was qualitative data triangulated? Was there any data overlap from the quantitative/survey data?  Also, what kind of sampling strategy was employed?

9.     What about other characteristics not found in the tables? E.g.  socioeconomic status? Low income/educational attainment?

10.  Perhaps the section on Limitations should be rewritten as Strengths and Limitations – it is good to see some limitations.  What are the strengths of this study? For instance, validated survey tools were used.  

Thank you for the opportunity to review this manuscript.

Table 2 there are some acronyms that need to be written out first before they are written as SFA, MUFA and CHO.  Is CHO cholesterol? Tables 2 and 3 also have a spelling error and “Cafein” should be “Caffeine” and “Controles” should be “Control”

Author Response

This study used multiple surveys and interviews to gather data to explain how quarantine habits and lifestyle factors could be risk factors in frequency of irritable bowel syndrome among Chilean participants.  This study is important and the abstract reads well; however, I have some recommendations for this paper that could improve it further:

1. Regarding lines 86-87, key demographics about mortality from COVID-19 may be beneficial to the introduction section. 

RESPONSE: This section has been modified.

2. Please elaborate if a power analysis was conducted for the effect size, sample size, and statistical power? The sample size was low for surveys. 

RESPONSE: We use non-probabilistic sampling for convenience, we do not use formulas. The size is low due to the number of participants during the pandemic. We include it as a limitation.

3. Lines 93-94 may need to be reworded as it currently states that inclusion criteria were engaging in physical activity or not (it could not be both so I think it should be “engaging in physical activity”

RESPONSE: This text has been modified.

4. For section 2.3, what was the response rate for the surveys?

RESPONSE: This sentence was added to 2.2.

5. Table 2 there are some acronyms that need to be written out first before they are written as SFA, MUFA and CHO.  Is CHO cholesterol? Tables 2 and 3 also have a spelling error and “Cafein” should be “Caffeine” and “Controles” should be “Control”

RESPONSE: This text was added and edited.

6. Table 4 requires more info; was it logistic regression or linear regression? Line 154 lists both erroneously. What was r squared values? You should also indicate that the p-value was statistically significant at P<0.05 under the table. 

RESPONSE: The presentation of results has been improved

7. The limitations section should certainly include the fact that the survey data used very small sample sizes.

RESPONSE: This sentence was added to the section.

8. Methods – Was this a mixed-methods study? If yes, were the interviews recorded using Google Meet? It seems like the interviews were not really qualitative interviews but were rather meant to administer survey instruments – if that is the case, then perhaps rephrase this section to state this? Otherwise, more information is required. E.g. were interview transcripts generated? Were transcripts thematically analyzed? Were they coded? How was qualitative data triangulated? Was there any data overlap from the quantitative/survey data?  Also, what kind of sampling strategy was employed?

RESPONSE: It is not a mixed methods study. The calls were only to contact the participants. We improve this part of the methods.

9. What about other characteristics not found in the tables? E.g.  socioeconomic status? Low income/educational attainment?

RESPONSE: They were not important, the participants had similar demographic data, the results are described.

10. Perhaps the section on Limitations should be rewritten as Strengths and Limitations – it is good to see some limitations.  What are the strengths of this study? For instance, validated survey tools were used.  

 RESPONSE: The strengths and limitations of the study have been brought together

Round 2

Reviewer 2 Report

The manuscript has been sufficiently improved to warrant publication in IJERPH. Nevertheless, the problem under study does not have much scientific novelty; the research methods and the results obtained seem trivial.

Requires text editing, style correction, and use of proper terminology to improve readability.

Author Response

RESPONSE TO REVIEWERS
O1: The manuscript has been sufficiently improved to warrant publication in IJERPH. Nevertheless, the problem under study does not have much scientific novelty; the research methods and the results obtained seem trivial.

RESPONSE: The main novelty of the study is to demonstrate for the first time the effects of quarantine in participants with IBS. This information has not been reported before in Chile and is relevant to understand the changes related to the COVID-19 pandemic. From this, prevention and care activities can be proposed for these patients, in order to improve or recover their healthy lifestyles.
We added a previous case report that described COVID-19 symptoms in a group of patients with IBS, but that did not perform a complete analysis of their life factors. In that sense, this study is relevant.