A Patient-Centered Ethical Framework for Irritable Bowel Syndrome Care: Communication, Trust, Nutrition-Sensitive Care, and Self-Management

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for allowing me to be involved in reviewing this article. I congratulate the authors on such an outstanding work. I enjoyed reading it and I have a few comments and suggestions. 

1. How does this review differ from the following reviews: https://pmc.ncbi.nlm.nih.gov/articles/PMC11074491  https://link.springer.com/article/10.1007/s40746-026-00366-8
2. I would recommend narrowing the research question to make it about communication to shape IBS managment through patient centered care
3. Can you make sure it is clear this is a narrative review in the abstract, please?
4. The introduction is very long and heavily cited. Instead of 6 paragraphs and 30 citations, try to limit it to 4 paragraphs with 10-15 citations. 
5. I am OK there is no methodology section as this is a narrative review. 
6. I like the flow of the results but I hope you add more details and subheadings to importance of continuity of care and relationships in managment of IBS to the section 2. 
7. Does autonomy have a limit in IBS managment? What do you do when a patient keep demanding more investigation? Can you talk about that?
8. Can you talk about how to communicate psychological support, CBT, and mindfulness to manage IBS? 
9. Can you talk about how to communicate exercise and Yoga to manage IBS? 
10. Can you talk about how to communicate about misinformation about IBS? 
11. Having four figures is too much for a narrative review. Figure one is hard to read with the different shades of bright colors. Either delete it or make it into black and white. Figure 3 can be made into a table for better readability. I think limiting it to two figures would be more ideal. 
12. The figure captions are way too long and should be more concise. 
13. Please remove the disclosure about using AI to generate the figures to the bottom of the article instead of adding it to every figure's caption.
14. The conclusion is just too long. Please, make it more concise and to the point: two paragraphs would be sufficient. 

 

Author Response

Reviewer 1

Thank you for allowing me to be involved in reviewing this article. I congratulate the authors on such an outstanding work. I enjoyed reading it and I have a few comments and suggestions.

Response to Reviewer 1:   Thank you very much for your positive feedback on our manuscript.

 

Comment 1: How does this review differ from the following reviews: https://pmc.ncbi.nlm.nih.gov/articles/PMC11074491  https://link.springer.com/article/10.1007/s40746-026-00366-8

 

Response to comment 1: We thank the reviewer for this comment. We agree that the cited reviews are relevant to the broader field of IBS management; however, the concept of our manuscript is substantially different. Tetali et al. provide a narrative review of therapeutic modalities for adult IBS, including pharmacologic therapies, dietary modification, probiotics, fecal microbiota transplantation, behavioral therapy, complementary approaches, and integrated care. Similarly, Lebowitz et al. discuss management strategies for pediatric IBS, with emphasis on dietary, pharmacologic, neurostimulation, psychological, and family-centered approaches.

In contrast, our manuscript is not designed as a treatment-oriented review or therapeutic algorithm for IBS. Its primary contribution is the development of a patient-centered ethical framework for IBS care. We focus on how ethical communication, validation, relational autonomy, trust, stigma, uncertainty, patient-reported outcomes, and nutrition-sensitive self-management shape the clinical encounter and influence patient engagement. Dietary and behavioral aspects are discussed within this ethical framework, not as a comprehensive review of available treatment options. Therefore, the novelty of our review lies in reframing IBS care through a bioethical and patient-centered setting, rather than summarizing the efficacy of specific therapeutic interventions.     

 

Comment 2: I would recommend narrowing the research question to make it about communication to shape IBS managment through patient centered care

 

Response to comment 2: We thank the reviewer for this helpful suggestion. We agree that the review should be centered on how communication shapes IBS management through patient-centered care. This is the main conceptual focus of our manuscript, where communication is presented as an ethical and therapeutic intervention that supports trust, validation, shared decision-making, self-management, and individualized care. Nutritional management and patient-reported outcomes are discussed within this patient-centered communication framework rather than as independent therapeutic topics. We have refined the aim of the manuscript to more clearly emphasize communication as the central mechanism through which patient-centered care can shape IBS management, as suggested (page 3, lines 134-137).

 

Comment 3:  Can you make sure it is clear this is a narrative review in the abstract, please?

Response to comment 3: We have made it clear, as suggested (page 1, line 19).       

 

Comment 4: The introduction is very long and heavily cited. Instead of 6 paragraphs and 30 citations, try to limit it to 4 paragraphs with 10-15 citations.

 

Response to comment 4: We thank the reviewer for this suggestion. We have streamlined the Introduction by removing several highly mechanistic sentences, while preserving the overall rationale of the manuscript. We retained the structure needed to introduce IBS as a disorder of gut–brain interaction, its clinical and psychosocial burden, and the need for a communication-centered, patient-centered ethical framework.

 

Comment 5: I am OK there is no methodology section as this is a narrative review

Response to comment 5:  We thank the reviewer for this comment.

 

Comment 6:  I like the flow of the results but I hope you add more details and subheadings to importance of continuity of care and relationships in managment of IBS to the section 2.

Response to comment 6: We have revised Section 2 by adding subheadings to the section and by expanding the discussion on continuity of care and therapeutic relationships in IBS management (page 4, lines 170-182).

  

Comment 7:  Does autonomy have a limit in IBS managment? What do you do when a patient keep demanding more investigation? Can you talk about that?

Response to comment 7: We thank the reviewer for raising this important point. We agree that autonomy in IBS care should not be interpreted as unlimited patient demand for further investigations. We have therefore added a short subsection discussing the ethical limits of autonomy when patients repeatedly request additional testing (page 5, lines 206-213).

  

Comment 8:  Can you talk about how to communicate psychological support, CBT, and mindfulness to manage IBS?

Response to comment 8: We have incorporated these data to the 3.4 section “Discussing Psychological Factors with Sensitivity” to clarify how psychological support, cognitive behavioral therapy, and mindfulness-based strategies can be communicated in a non-stigmatizing way within integrated IBS care, as suggested (page 7, lines 295-302).

    

Comment 9:  Can you talk about how to communicate exercise and Yoga to manage IBS? Response to comment 9: We have added a brief statement on how physical activity should be communicated as a supportive and individualized self-management strategy in IBS (pages 7-8, lines 302-309). We have referred to physical activity rather than yoga, because current IBS guidance discusses exercise/physical activity more broadly, whereas yoga is not presented as a core or clearly established IBS management recommendation.  

 

Comment 10:  Can you talk about how to communicate about misinformation about IBS? Response to comment 10: We have incorporated these data to the 3.6 section “3.6 Ethical Implications of Communication in IBS Management” to clarify how psychological support, cognitive behavioral therapy, and mindfulness-based strategies can be communicated in a non-stigmatizing way within integrated IBS care, as suggested (page 10, lines 419-423).

 

Comment 11:  Having four figures is too much for a narrative review. Figure one is hard to read with the different shades of bright colors. Either delete it or make it into black and white. Figure 3 can be made into a table for better readability. I think limiting it to two figures would be more ideal.

Response to comment 11: We thank the reviewer for this helpful comment. We revised Figure 1 into a more accessible, high-contrast format with reduced color intensity to improve readability. Regarding the number of figures, we respectfully retained the remaining figures, as each one illustrates a distinct component of the proposed narrative framework. Figure 3 was kept as a figure rather than converted into a table because it presents a stepwise, patient-centered pathway for nutrition-sensitive IBS care, which is more clearly conveyed visually. We believe that the figures support the conceptual structure of the review and improve readability.    

 

Comment 12:  The figure captions are way too long and should be more concise.

Response to comment 12: We thank the reviewer for this suggestion. We have shortened the figure captions to improve readability and avoid unnecessary repetition.     

 

Comment 13:  Please remove the disclosure about using AI to generate the figures to the bottom of the article instead of adding it to every figure's caption.

Response to comment 13: We would like to clarify that no artificial intelligence tool was used to generate the figures. The figures were personally designed by the authors using BioRender. Therefore, the statement “Created with BioRender.com” was retained in the figure legends as a licensing statement, as required by BioRender for figures created using its platform, and not as an AI disclosure.      

 

 Comment 14: The conclusion is just too long. Please, make it more concise and to the point: two paragraphs would be sufficient.

Response to comment 14: We have shortened the Conclusion and revised it, emphasizing the main contribution of the review without repeating details already discussed in the manuscript, as suggested.     

 

Comment 15: The English could be improved to more clearly express the research.

Response to comment 15: We have thoroughly checked and revised the manuscript to improve English language, grammar, and overall readability.

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript addresses a highly relevant and often underexplored aspect of irritable bowel syndrome (IBS) management, namely the ethical dimensions of patient-centered care. The topic is timely, clinically meaningful, and the proposed framework provides an original perspective that integrates communication, relational autonomy, nutritional management, self-management, and patient-reported outcomes within an ethical context.

Introduction

The introduction is well structured and provides a comprehensive overview of the pathophysiology, epidemiology, and clinical burden of IBS. Nevertheless, the ethical rationale underlying the review could be strengthened further. In particular, it would be beneficial to more explicitly emphasize why IBS represents a unique ethical challenge compared with other chronic gastrointestinal disorders. Key elements such as the absence of definitive biomarkers, diagnostic uncertainty, symptom invalidation by healthcare professionals, and the social stigma frequently experienced by patients should be introduced earlier and framed as central reasons supporting the need for a dedicated ethical framework.

Methods

Although this is a narrative and conceptual review, some methodological aspects could be clarified. The figures and conceptual models are clear, informative, and visually effective; however, greater transparency would be appreciated regarding whether these frameworks are derived from previously published theoretical models or represent original syntheses developed by the authors. Additional clarification concerning the process used to construct the proposed ethical framework would strengthen its scientific credibility and help readers better understand its conceptual foundations.

Results and Thematic Development

One of the most innovative sections of the manuscript is the discussion of relational autonomy. However, the practical application of this concept could be illustrated more explicitly. Including examples showing how relational autonomy may guide dietary decision-making, treatment selection, or collaborative symptom-monitoring strategies would improve the translational value of the framework and facilitate its implementation in routine clinical practice.

The section dedicated to Patient-Reported Outcomes (PROs) could also be further expanded. While the manuscript adequately describes the available instruments and their limitations, their ethical significance is only partially explored. Greater emphasis could be placed on how PROs formally incorporate the patient’s voice into clinical decision-making, promote autonomy, reduce paternalistic approaches, and support more equitable care. Furthermore, the inclusion of a summary table describing the principal IBS- specific PRO isntruments, including assessed domains, strengths, and limitations, would substantially enhance the practical usefulness of the review.

The nutritional management section is well organized and supported by current evidence. However, it could benefit from a more detailed discussion of the psychological dimensions of eating behaviors in IBS. Food-related anxiety, restrictive eating behaviors, and the psychosocial consequences of dietary restrictions are increasingly recognized within the literature and deserve further consideration. Likewise, a deeper discussion of the ethical implications related to the economic costs of specialized diets, access to experienced dietittians, and disparities in access to nutritional care would further strengthen this section.

The self-management section appropriately highlights the importance of active patient engagement. Nevertheless, the theoretical foundation could be reinforced through greater integration of established behavioral theories, such as Bandura’s Self-Efficacy Theory, Self-Care Theory, and Chronic Disease Self-Management models. Incorporating these perspectives would provide a stronger conceptual link between the ethical principles discussed and the behavioral mechanisms that influence clinical outcomes. In addition, the extensive literature available in inflammatory bowel disease (IBD) regarding self-care, self-efficacy, and patient engagement may offer valuable insights and could serve as a useful source of comparison and theoretical support.

Discussion and Conclusions

The conclusions effectively summarize the main messages of the review and remain consistent with its objectives. However, dthey could be strengthened by including a broader reflection on future directions. In particular, it would be valuable to discuss how the proposed ethical framework could be empirically validated, implemented in routine clinical practice, and incorporated into educational and training programs for healthcare professionals. Such considerations would enhance the translational value of the manuscript and provide a clearer roadmap for future research and implementation efforts.

Overall, this is a well-written, clinically relevant, and original manuscript that makes a meaningful contribution to the literature on patient-centered care and ethical IBS management. The suggested revisions are intended to further strengthen the conceptual depth, practical applicability, and scientific rigor of the proposed framework.

Author Response

Reviewer 2

This manuscript addresses a highly relevant and often underexplored aspect of irritable bowel syndrome (IBS) management, namely the ethical dimensions of patient-centered care. The topic is timely, clinically meaningful, and the proposed framework provides an original perspective that integrates communication, relational autonomy, nutritional management, self-management, and patient-reported outcomes within an ethical context.

Response to Reviewer 2: Thank you very much for your positive feedback on our manuscript.

 

Comment 1: The introduction is well structured and provides a comprehensive overview of the pathophysiology, epidemiology, and clinical burden of IBS. Nevertheless, the ethical rationale underlying the review could be strengthened further. In particular, it would be beneficial to more explicitly emphasize why IBS represents a unique ethical challenge compared with other chronic gastrointestinal disorders. Key elements such as the absence of definitive biomarkers, diagnostic uncertainty, symptom invalidation by healthcare professionals, and the social stigma frequently experienced by patients should be introduced earlier and framed as central reasons supporting the need for a dedicated ethical framework.

 

Response to comment 1: We thank the reviewer for this helpful suggestion. We have revised the Introduction to more explicitly frame IBS as a distinct ethical challenge. In particular, we now emphasize earlier in the manuscript that the absence of definitive biomarkers, diagnostic uncertainty, symptom invalidation, and social stigma create specific ethical concerns that justify the need for a dedicated patient-centered ethical framework (pages 2-3, lines 91-96).  

 

Comment 2: Although this is a narrative and conceptual review, some methodological aspects could be clarified. The figures and conceptual models are clear, informative, and visually effective; however, greater transparency would be appreciated regarding whether these frameworks are derived from previously published theoretical models or represent original syntheses developed by the authors. Additional clarification concerning the process used to construct the proposed ethical framework would strengthen its scientific credibility and help readers better understand its conceptual foundations.

Response to comment 2: As a narrative and conceptual review, this manuscript does not aim to provide a systematic evidence synthesis or treatment algorithm. The proposed framework and figures represent original syntheses developed by the authors through integration of published literature on IBS management, ethical communication, relational autonomy, patient-centered care, nutrition-sensitive care, patient-reported outcomes, and supported self-management. These conceptual models were designed to organize existing clinical and ethical evidence into a practical framework for routine IBS care, rather than to reproduce or adapt a single previously published theoretical model.

 

Comment 3:  One of the most innovative sections of the manuscript is the discussion of relational autonomy. However, the practical application of this concept could be illustrated more explicitly. Including examples showing how relational autonomy may guide dietary decision-making, treatment selection, or collaborative symptom-monitoring strategies would improve the translational value of the framework and facilitate its implementation in routine clinical practice.

Response to comment 3: We have added practical examples illustrating how relational autonomy can guide IBS care, including dietary decision-making, treatment selection, and collaborative symptom monitoring. This addition clarifies how the ethical framework can be translated into routine clinical practice (page 4, lines 195-205).     

 

Comment 4: The section dedicated to Patient-Reported Outcomes (PROs) could also be further expanded. While the manuscript adequately describes the available instruments and their limitations, their ethical significance is only partially explored. Greater emphasis could be placed on how PROs formally incorporate the patient’s voice into clinical decision-making, promote autonomy, reduce paternalistic approaches, and support more equitable care. Furthermore, the inclusion of a summary table describing the principal IBS- specific PRO isntruments, including assessed domains, strengths, and limitations, would substantially enhance the practical usefulness of the review.

Response to comment 4:  We thank the reviewer for this valuable suggestion. We have expanded the section on patient-reported outcomes to discuss in more detail their ethical significance in IBS care (page 11, lines 445-456). In addition, we have added a summary table presenting principal IBS-related PRO instruments, including assessed domains, strengths, and limitations, to improve the practical usefulness of the review (page 12).

 

Comment 5: The nutritional management section is well organized and supported by current evidence. However, it could benefit from a more detailed discussion of the psychological dimensions of eating behaviors in IBS. Food-related anxiety, restrictive eating behaviors, and the psychosocial consequences of dietary restrictions are increasingly recognized within the literature and deserve further consideration. Likewise, a deeper discussion of the ethical implications related to the economic costs of specialized diets, access to experienced dietittians, and disparities in access to nutritional care would further strengthen this section.

Response to comment 5: We have expanded the nutritional management section to further address the psychological dimensions of eating behaviors in IBS, including food-related anxiety, restrictive eating, fear of symptom exacerbation, and the psychosocial burden of dietary avoidance (page 13, lines 522-529). We have also added further discussion of the ethical implications of specialized dietary interventions, particularly economic cost, access to experienced dietitians, food availability, and disparities in nutritional care (page 14, lines 601-606).  

 

Comment 6:  The self-management section appropriately highlights the importance of active patient engagement. Nevertheless, the theoretical foundation could be reinforced through greater integration of established behavioral theories, such as Bandura’s Self-Efficacy Theory, Self-Care Theory, and Chronic Disease Self-Management models. Incorporating these perspectives would provide a stronger conceptual link between the ethical principles discussed and the behavioral mechanisms that influence clinical outcomes. In addition, the extensive literature available in inflammatory bowel disease (IBD) regarding self-care, self-efficacy, and patient engagement may offer valuable insights and could serve as a useful source of comparison and theoretical support.

Response to comment 6: We thank the reviewer for this thoughtful suggestion. We agree that established behavioral concepts can strengthen the theoretical basis of the self-management section. Accordingly, we have added a brief discussion linking supported self-management in IBS with self-efficacy, self-care, and chronic disease self-management models. We also briefly mention the IBD literature as a useful comparative field, while avoiding an extensive discussion because the focus of the present review remains IBS-specific ethical care (page 16, lines 664-675).     

 

Comment 7:  The conclusions effectively summarize the main messages of the review and remain consistent with its objectives. However, dthey could be strengthened by including a broader reflection on future directions. In particular, it would be valuable to discuss how the proposed ethical framework could be empirically validated, implemented in routine clinical practice, and incorporated into educational and training programs for healthcare professionals. Such considerations would enhance the translational value of the manuscript and provide a clearer roadmap for future research and implementation efforts.

 

Response to comment 7:  We have expanded the Conclusion by adding a brief future directions paragraph. This addition discusses how the proposed ethical framework could be empirically evaluated, implemented in routine IBS care, and incorporated into educational and training programs for healthcare professionals (page 21, lines 882-891).     

  

Comment 8:  Overall, this is a well-written, clinically relevant, and original manuscript that makes a meaningful contribution to the literature on patient-centered care and ethical IBS management. The suggested revisions are intended to further strengthen the conceptual depth, practical applicability, and scientific rigor of the proposed framework.

Response to comment 8: We thank the reviewer for the positive evaluation of our manuscript and for the thoughtful and constructive suggestions. We have carefully revised the manuscript in response to the reviewer’s comments, with the aim of strengthening the conceptual depth, practical applicability, and scientific rigor of the proposed patient-centered ethical framework for IBS care.