Effects of the Traditional Mediterranean Diet in Childhood Recurrent Acute Rhinosinusitis
Round 1
Reviewer 1 Report
Abstract
Line 20 – The authors state “Adoption of the TMD could have promising effects in the prevention and treatment of…”. I believe that prevention was assessed in this study, but not treatment;
Introduction
Line 27 – When the authors use the expression “When school activities begin” it seems that school activities have an influence of the appearance of the symptoms. Please re-write it;
Line 61- What does the authors mean with “disparate results”?
Line 67 – Despite depicted in the discussion a small explanation regarding the connection of inflammation and the disease events described in the paper should be provided in the introduction;
Materials and Methods
The nationality(ies) of the studied population should be indicated mostly in order to understand if the study was performed in a Mediterranean country. Implications might exist such as the adherence degree to this diet previous to the study, or the more or less difficulties in promoting this adherence;
Figure 1- For food quality measurements the authors should indicate if these are validated instruments;
Line 111 – Please spell out URTI, AOM, OME, PNO and SR and associate these with the study; indicate the criteria to choose these conditions and if they are confounders;
Line 142 – What does the author mean with “degree of satisfaction with the intervention”? If they like the diet, if the parents are satisfied with the adherence achieved, or other?
Line 176 – The authors mention “At each visit, we evaluated the nutritional tests, and together with the patients and their parents, we analysed any difficulties that may have arisen and examined how we could modify behaviour to obtain the best results.”. Since this study was not undertaken after a period of adaptation to the diet and changes in behaviour to obtain best results occurred, this potencial source of bias should be discussed;
Table 2 – Please indicate if physical activity was considered in the questionnaire or not, since it is indicted “Be physically active every day, since it is just as important as eating well”; If so, I suggest not consider this data because Mediterranean lifestyle includes many other factors, such as meals with friends and family, along with the physical activity. I believe the idea here is specifically address to diet;
Result
Figure 2 – “No antibiotics” is not clear; previous to Diet intervention no use of antibiotics was higher? It does not seem to make sense;
Line 266 - Please define “poor-quality diet”;
Table 8: Traditional Mediterranean Diet Test – similar to table 2, other factors such as night sleep were included. This is not diet but Mediterranean lifestyle. The authors should consider this in the title, objectives or simply do ot consider these variables;
Line 269 – “Despite the good score obtained with the KidMed test, the patients demonstrated the same incidence of ARS. However, when applying the TMD test, we obtained statistically significant results in the evolution of ARS”. Please discuss these results.
Author Response
Reviewer 1
Comments and Suggestions for Authors
Abstract
Line 20 – The authors state “Adoption of the TMD could have promising effects in the prevention and treatment of…”. I believe that prevention was assessed in this study, but not treatment;
Answer: The patients studied had been diagnosed with recurrent acute rhinosinusitis (RSAR). After nutritional intervention, their symptoms improved and they were no longer classified as RSAR. We believe that nutritional intervention can also be classified as nutritional therapy, since it was instrumental in helping to resolve the illness. A similar example is seen in the way that vitamin D and foods that contain it are considered to be both preventive and therapeutic for rickets.
Introduction
Line 27 – When the authors use the expression “When school activities begin” it seems that school activities have an influence of the appearance of the symptoms. Please re-write it;
Answer: At the beginning of the school year and with the arrival of winter ...
Line 61- What does the authors mean with “disparate results”?
Answer: It is modified by different results.
Line 67 – Despite depicted in the discussion a small explanation regarding the connection of inflammation and the disease events described in the paper should be provided in the introduction;
Answer and added: This anti-inflammatory action is based on the reduction of pathologies related to oxidative stress, chronic inflammation and the inflammatory system. Our hypothesis is that diet and individual nutrients can influence the resolution of RSAR by stabilizing the inflammatory and immune mechanisms.
Materials and Methods
The nationality(ies) of the studied population should be indicated mostly in order to understand if the study was performed in a Mediterranean country. Implications might exist such as the adherence degree to this diet previous to the study, or the more or less difficulties in promoting this adherence;
Answer: This study was carried out in the Mediterranean area, in the community of Castilla la Mancha (Spain).
Figure 1- For food quality measurements the authors should indicate if these are validated instruments;
Please see our response to your comment about line 269
Line 111 – Please spell out URTI, AOM, OME, PNO and SR and associate these with the study; indicate the criteria to choose these conditions and if they are confounders;
Answer and added: The following variables were considered, as they are closely related to the pathology studied: upper respiratory tract infections (URTI), acute otitis media (AOM), otitis media with effusion (OME), persistent nasal obstruction (PNO), and recurrent wheezing (RW)
Line 142 – What does the author mean with “degree of satisfaction with the intervention”? If they like the diet, if the parents are satisfied with the adherence achieved, or other?
Answer and added: Degree of satisfaction with the therapeutic effects of the nutritional intervention.
Line 176 – The authors mention “At each visit, we evaluated the nutritional tests, and together with the patients and their parents, we analysed any difficulties that may have arisen and examined how we could modify behaviour to obtain the best results.”. Since this study was not undertaken after a period of adaptation to the diet and changes in behaviour to obtain best results occurred, this potential source of bias should be discussed;
Answer and added: Most of the families were accustomed to the traditional (Mediterranean) diet, although its implementation was highly contaminated by industrial pressure. Thus, it was necessary to help them differentiate one from the other.
Table 2 – Please indicate if physical activity was considered in the questionnaire or not, since it is indicated “Be physically active every day, since it is just as important as eating well”; If so, I suggest not consider this data because Mediterranean lifestyle includes many other factors, such as meals with friends and family, along with the physical activity. I believe the idea here is specifically address to diet;
Answer: This table sets out the recommendations of the Mediterranean Diet Foundation. In the study we did not measure or schedule physical activity, but rather included these only as general recommendations.
The following sentence has been added: Physical activity and other variables of the Mediterranean lifestyle were not considered, programmed, or monitored, but were rather included only as general recommendations.
Result
Figure 2 – “No antibiotics” is not clear; previous to Diet intervention no use of antibiotics was higher? It does not seem to make sense;
Answer: It is modified by No. of antibiotics and refers to the number of antibiotics prescribed.
Line 266 - Please define “poor-quality diet”;
Answer: In the methodology, a 'poor quality' diet is defined as a KidMed test score below or equal to seven points.
Table 8: Traditional Mediterranean Diet Test – similar to table 2, other factors such as night sleep were included. This is not diet but Mediterranean lifestyle. The authors should consider this in the title, objectives or simply do not consider these variables;
Answer: The study has evaluated the effects of the Mediterranean diet. Other potentially related aspects, such as physical exercise, night sleep and sociability, have not been evaluated. We have not considered them as variables, although their general consideration has helped us to publicize and promote the Mediterranean lifestyle.
Line 269 – “Despite the good score obtained with the KidMed test, the patients demonstrated the same incidence of ARS. However, when applying the TMD test, we obtained statistically significant results in the evolution of ARS”. Please discuss these results.
Answer: Prior to the development of our study, we promoted the application of a validated test, such as the KidMed test [34], with the intention of preventing and treating inflammatory and recurrent diseases, as well as overweight and obesity [33]. Despite this, we did not obtain satisfactory results so we decided to implement a new TMD test, which collected information about important aspects of the Mediterranean diet that had not previously been detailed. Many of the children who had an optimal KidMed test failed on the TMD index. It was only when they began to show improved scores with the new test that we obtained satisfactory results.
In the KidMed test, some variables that we believe are important are not considered. For example, no differences are noted between refined cereals and whole grains, nor are there any references to the consumption of sugar or sugary industrial juices. Also, in general, glycaemic index/glycaemic load is not taken into account. In the lipid section, saturated fat consumption is neither limited nor evaluated. The test does not allow for detection of excess consumption of animal proteins. Also, no assessment is made of the consumption of raw food, nor is the minimum amount to be taken specified. Serving sizes and schedules are not taken into account. Completing the KidMed test has not been shown to be effective in our study. We believe that these small nuances that we have proposed in the TMD test are important for obtaining satisfactory results in the examination of recurrent inflammatory diseases, in particular RSAR.
Reviewer 2 Report
This is a very interesting paper in which authors try to assess the effects of an intervention with the traditional Mediterranean diet in children with recurrent acute and chronic rhinosinusitis. However, it needs some major revisions:
1) Abstract: Line 15. Replace "variables" with "characteristics".
2) Figure 1: 1st circle: Please replace "y" with "and"
3) Methodology: I would suggest to remove phrases like " The main variable..." or "The following secondary variables were considered...".
4) Lines 138-147: Is this questionnaire validated?
5) Table 1: This index was based on a categorical variable, i.e. " 0:nothing, 1:something, 2: quite, 3: much" or a continuous one? How was 2,27, for example, computed?
6) Table 4 & 6: Is BMI index proper for children?
7) Table 5: Please rename the second column as "year of treatment".
8) Table 5: "Degree of involvement of ARS" Is this a categorical or continuous variable? If it is a categorical variable it should be presented a %.
9) Table 5: Please provide further information concerning the presentation of the data. For example, mean ± standard deviation and how p-values are obtained.
10) Figure 2: Please change the description of the footnote.
11) Table 7: This comment concerns all Tables and Figures. They should stand alone, with all the necessary information. Please provide further information about what it is presented, either in a footnote either with a better table description.
12) Table 8: a p-value is needed to better understand if there are any differences.
13) Conclusions: line 420: there is a double space between "that" and "application".
14) Ref 24. It should be replaced by a review or meta-analysis paper.
Author Response
This is a very interesting paper in which authors try to assess the effects of an intervention with the traditional Mediterranean diet in children with recurrent acute and chronic rhinosinusitis. However, it needs some major revisions:
1) Abstract: Line 15. Replace "variables" with "characteristics".
Answer: This replacement has been made.
2) Figure 1: 1st circle: Please replace "y" with "and"
Answer: Replaced
3) Methodology: I would suggest to remove phrases like " The main variable..." or "The following secondary variables were considered...".
Answer and added: The study variables were the number of RSA ....
4) Lines 138-147: Is this questionnaire validated?
Answer: We have relied on other similar questionnaires that have been validated.
5) Table 1: This index was based on a categorical variable, i.e. " 0: nothing, 1: something, 2: quite, 3: much" or a continuous one? How was 2,27, for example, computed?
Answer: The questionnaire was implemented at four months and again at one year after the intervention began. It was scored by the paediatrician, based on the symptomatic evolution and the responses of the family at that time. The average score obtained by all patients is the one that is reflected in the table. The 2.27 value is the mean score obtained by the patients on a specific item.
6) Table 4 & 6: Is BMI index proper for children?
Answer: BMI in children is assessed using percentile tables, in the same way as weight and height. It is a useful index to assess the height/weight relationship and its evolution. In this study, we were interested in verifying that the limitation of certain foods did not hinder proper development of height/weight and BMI.
7) Table 5: Please rename the second column as "year of treatment".
Answer: Changed to 'year of treatment'.
8) Table 5: "Degree of involvement of ARS" Is this a categorical or continuous variable? If it is a categorical variable it should be presented a %.
Answer: There is an error that we have corrected: this item refers to the degree of involvement of the persistent nasal obstruction (PNO) observed by the paediatrician, and not to the degree of involvement of the ARS, (0 = mild, 1 = moderate, 2 = severe).
9) Table 5: Please provide further information concerning the presentation of the data. For example, mean ± standard deviation and how p-values are obtained.
Answer: Mean ± standard deviation has been added.
10) Figure 2: Please change the description of the footnote.
Answer: Done
11) Table 7: This comment concerns all Tables and Figures. They should stand alone, with all the necessary information. Please provide further information about what it is presented, either in a footnote either with a better table description.
Answer: Done
12) Table 8: a p-value is needed to better understand if there are any differences.
Answer: The table shows that the improvement in nutritional quality was notable, going from a low score to an optimal one. However, without a doubt, it would have been interesting to include the p-value to see if there are differences.
13) Conclusions: line 420: there is a double space between "that" and "application".
14) Ref 24. It should be replaced by a review or meta-analysis paper.
We have changed this to read: 24. Kargin D, Tomaino L, Serra-Majem L. 'Experimental Outcomes of the Mediterranean Diet: Lessons Learned from the Predimed Randomized Controlled Trial'. Nutrients. 2019; 11 (12): 2991. https://doi.org/10.3390/nu11122991
Round 2
Reviewer 2 Report
All the issues previously raised, have been corrected and included and no new issues have been introduced in the revision. Thus, the manuscript is now suitable for publication.
