What Are the Pearls and Pitfalls of the Dietary Management for Chronic Diarrhoea?

Round 1

Reviewer 1 Report

The authors have written a review on the dietary management of chronic diarrhoea. The review is written primarily for dietitians, reviewing causes of diarrhoea and linked this to the dietary treatment. Overall this was a valuable contribution to the literature as it links the underlying pathophysiology with dietary treatments. This clear linkage is evident in the sections on the low FODMAP diet, the gluten-free diet, lactose intolerance, sucrase-isomaltase deficiency and bile acid malabsorption. Inclusion of the sections on sucrase-isomaltase deficiency and bile acid malabsorption are particularly valuable in this context as may not be as familiar to many dietitians. The constant reminder to ensure nutritional adequacy of any exclusion diet was valuable as well the final table on the role of the dietitian. The authors discussion of the specific carbohydrate diet was useful as it demonstrated that it did not have the same evidence base as other treatments and furthermore that it did not have a plausible mechanism of action for how it might be effective. Likewise, the section on a low food chemical diet/ low histamine diet was a useful addition to the literature, although it is unclear the value of Table 4 in discussing the dietary management of diarrhoea.

Given the debate over the clinical validity of breath testing for diagnosing SIBO (10.1038/ajg.2017.233, 10.1111/jgh.13689) and the controversy over the use of antibiotics in treating SIBO, there was no acknowledgement of these controversies which have wide-ranging implications.

Major point

1. Acknowledge that the diagnosis of SIBO is controversial and that many think it is over-diagnosed, especially in IBS(D).

Minor points

1. Neither the title nor the abstract makes mention of irritable bowel syndrome, IBS is mentioned amongst the keywords. Given that the article discusses the management of IBS(D) as frequently as it does it would be useful to include IBS(D) within the abstract.
2. Is Table 4 necessary?
3. Could the authors please check that the correct abbreviation is used for the journal-title for the following references: 8. 23, 48, 59, 87, 108

Author Response

Dear reviewer

Thank you for taking the time to review the manuscript entitled “What are the pearls and pitfalls of the dietary management for chronic diarrhoea?” for the special edition “Nutritional Pearls and Pitfalls of Gastrointestinal Diseases”.  

Your review has been most helpful in revising the manuscript. We have made the following changes as outlined under each bolded comment.

Major point 1. Acknowledge that the diagnosis of SIBO is controversial and that many think it is over-diagnosed, especially in IBS(D)

Thank you for making this point, we agree it is important that it is addressed.   We have included a comment on this under section 2.2

Minor point 1. Neither the title nor the abstract makes mention of irritable bowel syndrome, IBS is mentioned amongst the keywords. Given that the article discusses the management of IBS(D) as frequently as it does it would be useful to include IBS(D) within the abstract.

We agree that the article discusses the management of IBS(D) frequently, however, the focus of the article is on the management of chronic diarrhoea.  While IBS(D) is a frequent cause of chronic diarrhoea, it is one of many.  We, therefore, do not think it should be isolated and added into the title or abstract as we would like to keep the focus of the article on all of the potential diet-related causes not just IBS(D).

Minor point 2: Is Table 4 necessary?

During the development of the manuscript, we discussed the relevance of table 4, as we did wonder how useful it was to the article.  We were keen to get feedback on the usefulness of the table from the reviewers.  We have now removed the table as we agree it does not add value to the article.  All references to this table have also been removed from the manuscript and other tables updated accordingly.

Minor point 3: Could the authors please check that the correct abbreviation is used for the journal-title for the following references: 8. 23, 48, 59, 87, 108

Thank you for bringing this to our attention, the references have all been corrected.

Once again thank you for your consideration of this manuscript.

Sincerely,

Leigh O’Brien

Leigh O’Brien
Department of Medicine

University of Otago – Christchurch

PO Box 4345

Christchurch 8140

New Zealand

Reviewer 2 Report

This is a thorough and topical review of the principles of dietary management of patients with chronic diarrhoea.  The authors describe how common this condition is, review the causes and how dietetic approaches will help.  Therapies that are reviewed for IBS-D/functional diarrhoea include the low-FODMAP diet, the specific carbohydrate diet, the low food chemical and low histamine diets.  Diets for SIBO, lactose intolerance, bile acid diarrhoea, sucrase-isomaltase deficiency and coeliac disease are addressed.  There are over 130 references.

The approach is clear, accurate and critical.  There are some minor areas that could be addressed:

1. Table 1 on Rome IV criteria has different duration for IBS and for FD.  These should be the same but the statement needs modification.
2. Table 3 is very big and I wonder if the format can be improved
3. SeHCAT is misspelt.
4. Non-coeliac gluten sensitivity is not included.  This could be added to the section on coeliac disease, or possibly discussed together with low-FODMAPs.  This will help to make the review more complete.

Author Response

Dear reviewer

Thank you for taking the time to review the manuscript entitled “What are the pearls and pitfalls of the dietary management for chronic diarrhoea?” for the special edition “Nutritional Pearls and Pitfalls of Gastrointestinal Diseases”.  

Your review has been most helpful in revising the manuscript. We have made the following changes as outlined under each bolded comment.

1. Table 1 on Rome IV criteria has different duration for IBS and for FD.  These should be the same but the statement needs modification.

Thank you for bringing this to our attention, it has been corrected to three months for both the table and comments

1. Table 3 is very big and I wonder if the format can be improved

We have made changes to the table to condense the number of words so that the table is reduced in size.  

1. SeHCAT is misspelt.

Thank you for bringing this to our attention, it has been corrected

1. Non-coeliac gluten sensitivity is not included.  This could be added to the section on coeliac disease, or possibly discussed together with low-FODMAPs.  This will help to make the review more complete.

We decided not to include a section on NCGS as we did not consider it to be an evidence-based diet therapy.  However, we do agree that it should be mentioned in the review.  We have therefore added a comment regarding NCGS to section 2.1.1

Once again thank you for your consideration of this manuscript.

Sincerely,

Leigh O’Brien

Leigh O’Brien
Department of Medicine

University of Otago – Christchurch

PO Box 4345

Christchurch 8140

New Zealand