Exploring Diet-Based Treatments for Atrial Fibrillation: Patient Empowerment and Citizen Science as a Model for Quality-of-Life-Centered Solutions

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I read the article intitulate Exploring Diet-Based Treatments for Atrial Fibrillation: Patient Empowerment and Citizen Science as a Model for Quality of Life-Centered Solutions. I think that this subject is very interesting and the article will be very useful for doctors and patients.

Please make some modifications like

- can you tell us more about the triggers? The patients drinks alcohol, coffeee? what is the quantity?

- it is a correlation between the episode of atrial fibrillation and the values of electrolytes?

- what type of atrial fibrillation?

- how many meals have our patients? what is the quantity of fruits and vegetables used by the patients?

- you don't discuss about the physical activity. Please tell us more about this subject.

Author Response

- can you tell us more about the triggers? The patients drinks alcohol, coffeee? what is the quantity?

• This is a relevant question. Patients report that several triggers may result in an AF episode. However, the degree or severity of the triggers is very individual, some people report that one cup of coffee/alcoholic beverage is already enough to provoke an AF episode, others mention several cups of coffee.

  We mention this item in the adapted manuscript.

  Introduction: ‘Also, specific triggers, that have been commonly reported by patients and are very individual, may drive AF episodes’.

- it is a correlation between the episode of atrial fibrillation and the values of electrolytes? what type of atrial fibrillation?

• It is well known that low electrolyte levels are related to AF episodes and increase in electrolytes is associated with less AF episodes.  This is mentioned in the introduction section: ‘These patient-initiated studies include L-glutamine [13], magnesium taurate and electrolytes as options to manage (paroxysmal) AF’.

  Also in section 4:

  ‘Therefore, low dietary intake of magnesium has been linked to a 50% higher risk of new-onset AF [71]. A meta-analysis of 20 randomized controlled trials has suggested that prophylactic magnesium supplementation may help prevent post-operative AF onset. Whereas a systematic review and meta-analyses on incident on new onset AF indicate no effect. However, the studies included represented a large variety in study population that may have hindered the outcomes [72]. Therefore, further studies on optimal dose, timing, and type of magnesium are required to obtain conclusive answers. ‘

  - how many meals have our patients? what is the quantity of fruits and vegetables used by the patients?

• In our review paper, the definition of whole foods plant-based diets and Mediterranean Diet diet are described in Table 2. The quantity of fruits and vegetables are not mentioned in the review as this differs between the various studies. As our review paper is meant to give an overview of the reported beneficial diet effects on risk factors for AF and episodes for AF, we believe that information on the quantity of fruits and vegetables is beyond the scope of our paper. We do mention now the quantity of meals per day in section 2:

  ‘Studies show that plant-based diets, which have been considered as three meals a day, help reduce many traditional risk factors for AF, including hypertension, hyperthyroidism, obesity, and diabetes [24, 25].’

  - you don't discuss about the physical activity. Please tell us more about this subject.

• Physical activity is very important to reduce the risk factors of AF. As mentioned in the introduction, in the current review, we discuss outcomes of diet-based treatments. Moreover, other lifestyle treatments are highlighted as some are brought up by patient initiatives. These patient-initiated studies include L-glutamine [13], magnesium taurate and electrolytes as options to manage (paroxysmal) AF [14].

  We believe that discussing the effect of exercise on risk factors of AF and AF episodes is a full review by itself and therefore beyond the scope of the current paper.

  Papers discussing physical activity in relation to AF have been published before and highlighted in our manuscript. See introduction: ‘So far, beneficial lifestyle interventions including weight loss, moderate exercise, mind-body exercise, and obstructive sleep apnea therapy have been investigated [12]. In addition, studies revealed that specific diets, notably the Mediterranean and plant-based diets may help to reduce the AF burden.’

Reviewer 2 Report

Comments and Suggestions for Authors

-regular excessive effort or sedentary lifestyle are also considered as risk factor - table 1 should be revised

- have authors found in literature some evidence for so called obesity paradox? It is postulated in many disorders as beneficial outcome in patients with overweight, dose it correspond in some way with loosing weight or diet changers?

- conclusion is too long, please revise it

Comments on the Quality of English Language

fine english

Author Response

-regular excessive effort or sedentary lifestyle are also considered as risk factor - table 1 should be revised

Thank you for this comment. We added to Table 1:

• Sedentary lifestyle [4, 5]
• Endurance sport [4, 5]

- have authors found in literature some evidence for so called obesity paradox? It is postulated in many disorders as beneficial outcome in patients with overweight, dose it correspond in some way with loosing weight or diet changers?

Thank you for this remark. As weight loss is not the primary focus of our paper and obesity paradox is under debate (see https://www.escardio.org/The-ESC/Press-Office/Press-releases/study-shows-obesity-paradox-does-not-exist-waist-to-height-ratio-is-a-better) we don’t highlight this topic in the current paper.

- conclusion is too long, please revise it

We respectfully disagree with you that the conclusion is too long. We think that the current conclusion is giving a good summary of the content described in the manuscript and therefore we like keep the conclusion as described in the original manuscript.