Fear of Food in Gastrointestinal Disease: A Framework Based on the Interpreted Experiences of Adults with Diverticular Disease

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This work deals with the dietary management of diverticulitis through a qualitative interview study including 5 thematic areas. Patients with diverticulitis and at least one hospitalisation were found to experience a cyclical thematic phenomenon amounted to'Fear of Food in Gastrointestinal Disease Framework".

It is a well-designed methodology considering ethical issues and analysing critically the obtained results while nice schematic interpretations are presented summarizing the methodological issues and results.Bibliography is up to date.

It is a well written paper helpful to clinical practitioners and dietitians.

Author Response

Thank you for your apt summary and support of this paper. We are grateful that the paper will be of help to clinical practitioners and dietetics to improve their support of adults with acute, uncomplicated diverticulitis. We have thoroughly reviewed the manuscript for grammar and readability to improve it further.

Reviewer 2 Report

Comments and Suggestions for Authors

Measurement of the psychological impact of disease ultimately digests down to a single word, fear which which largely stems for a lack of knowledge of what factors that combine to produce disease and their possible consequences. . The most meaningful segment, Implications for ...... and Practice, is anemic. The key to psychological intervention is getting the afflicted openly confront her fears within the patient/doctor relationship and educating the individual as to what she needs to understand to manage her potentially ongoing vulnerability to future episode. Explaining that diverticulosis is not a disease in the classical sense, but an out pocketing of the gastrointestinal mucosa that in isolated instances become becomes filled which, if closed from its connection the the gastrointestinal tract allows the entrapped microbiota to cause inflammation . If the rupture occurs, it will cause pain but does threaten one's life.

Author Response

Thank you for your synthesis of the thesis of our studies findings and for the recommendation to expand upon the implications for research and practice. The author group has consulted with the Gastroenterologist author (RC) to improve the implications of the studies findings so as to best support translation to practice and address the issue of fear identified in this study. The following paragraph has been added to the Implications for Research and Practice section (lines 458-470):

“There is thematic overlap for the cycle trigger ‘fear of food’ between this patient group and adults with eating disorders such as Avoidant/Restrictive Food Intake Disorder (ARFID) and anorexia nervosa [29-31]. The similarities in this cognitive presentation open avenues for further research. This includes a deeper exploration of the temporal outcomes associated with gastrointestinal conditions to examine if the fear of food trigger captured in this study and other literature [21-23] may spiral beyond the outcome of psychological pain to an eating disorder. If the ‘Fear of Food in Gastrointestinal Disease Framework’ is found to be describing a phenomenon early in the journey towards an eating disorder, it presents an opportunity for early intervention. This may be particularly valuable for ARFID where the etiology is not well understood [32, 33]. For patients with diverticular disease where there is no evidence of food as a pathophysiological trigger [26], evaluation of eating dis-order treatment approaches, such as exposure therapy, may provide feasible treatment options beyond improving communication and patient education [29].”