Onset of Ulcerative Colitis in a Patient with Type 2 Diabetes: Efficacy of a Plant-Based Diet for Both Diseases

Round 1

Reviewer 1 Report

This interesting case report merits further work on the mechanisms of PBD. It certainly opens valuable perspectives.

Author Response

Thank you very much for reviewing our paper.

Reviewer 2 Report

The Case report by Misturo Chiba et al., demonstrates onset of ulcerative colitis in a patient with type 2 diabetes mellitus. Here authors report a rare case of a 56-year-old man with 3-year history of diabetes had shown symptoms of ulcerative colitis and has been treated with plant-based diet and educational hospitalization.

·         It is a well-reported case, and the authors discussed the case briefly.

·         In the introduction section, references 7 and 8 reported that there is an increased risk of T2D in IBD patients and underlying mechanisms are not clear. I would suggest the authors to frame their rationale based on this report and rephrase the sentence” Because there are so many people affected by T2D, it is easily anticipated that some patients with T2D will develop UC”.

·         Figure 2 is blurred. Provide a clear picture of the graph.

Author Response

Thank you very much for reviewing our paper.

1. As described in the text, there are inconsistent results with respect to whether IBD is associated with increased risk for T2D. In reference 7, increased risk for T2D was observed only in ulcerative colitis but not in Crohn’s disease. In reference 8, the authors did not describe any underlying mechanisms. Therefore, at the moment there is no rational for increased risk of T2D in IBD.

I have deleted the sentence “Because there are so many people affected by T2D, it is easily anticipated that some patients with T2D will develop UC.” I have added the following sentence with addition of two references published last year. At any rate, an association between IBD and T2D has been reported in the literature [7-12].

Reference

11. Tseng, C.H. Metformin use is associated with a lower risk of inflammatory bowel disease in patients with type 2 diabetes mellitus. J. Crohns Colitis 2021, 15, 64-73.
12. Uwagbale, E.; Adeniran, O.G.; Adeniran, O.A.; Onukogu, I.; Agbroko, S.; Sonpal, N. In-hospital outcomes of inflammatory bowel diseases in patients with diabetes mellitus: a propensity score matching analysis. Cureus 2021, 13, e16566.                                                   

  2. Figure 2 was submitted according to the instructions for authors: tiff with a resolution of 330 dpi.

Reviewer 3 Report

This is the report of a single case. 

SPECIFIC COMMENTS

1. The authors state the co-occurence of T2DM and IBD has not been reported or scarcely reported. However, other authors state this to be a frequency occurrence (e.g. link: Inflammatory bowel disease, colorectal cancer and type 2 diabetes mellitus: The links - PubMed (nih.gov)

and refer to common mechanisms

2. The INTRO and DISCUSSION could be shortened and focused more. 

3. some words are unusual words (e.g. stabbing pain could be used instead of lancinating pain). There are also many awkward sentences and other aspects of language usage/word choice that should all be improved also

4. In terms of the diagnosis: the report details rectal endoscopic changes. Were these changes isolated to the rectum?

5. With regards the histology: the text says that these ruled out specific proctitis. Does this mean that the changes were consistent with ulcerative proctitis and that no evidence of other changes/. Again suggest to be more clear and specific here

6. Presumably he only had CPAP overnight? this is not clear

Author Response

Thank you very much for reviewing our paper.

1. There are more than several articles on co-occurrence of T2D and IBD. I have added two such references published last year.

References

11. Tseng CH. Metformin use is associated with a lower risk of inflammatory bowel disease in patients with type 2 diabetes mellitus. J Crohns Colitis 2021, 15, 64-73.
12. Uwagbale E, Adeniran OG, Adeniran OA, et al. In-hospital outcomes of inflammatory bowel diseases in patients with diabetes mellitus: A propensity score matching analysis. Cureus 2021, 13, e16566.

There have been no reported cases, however, where the relevant case was treated with a plant-based diet. I have added a phrase to the first sentence in Discussion and to the  conclusion in Discussion.

We described a scarcely reported case in which UC occurred in a patient with T2D and the patient was treated with a plant-based diet.

2. There have been no reports except from our group in which a plant-based diet has been routinely provided for IBD. Most of physicians treating patients with T2D recommend a diet based on dietary guidelines issued by nation-level dietary organizations rather than a plant-based diet. The increase in both diseases and other diet-related common chronic diseases is caused by the current problematic diet. This notion is probably new to most readers. Therefore, a reasonable introduction and discussion seems appropriate. We do not think our description in Introduction and Discussion is redundant.
3. Our manuscript was edited by a professional editor who is a native English speaker.

Lancinating pain is listed under the heading of pain in Dorland’s Illustrated Medical Dictionary (25th edition, W.B. Saunders, Philadelphia • London • Toronto 1974), but stabbing pain, which you suggested, is not listed.

4. Yes, inflammation was observed only in the rectum.
5. I have added a few sentences on histology.

Histologic examination revealed moderate infiltration of lymphocytes, plasma cells, and neutrophils. Non-caseating epithelioid granuloma was not found. Although crypt abscess was not found, neutrophils infiltration into glandular crypt epithelium was found. These findings were consistent with mild inflammation of UC.

6. I have added “overnight” for continuous positive airway pressure.

Thereafter, he continued overnight treatment with continuous positive airway pressure.

Allopurinol, metformin, and overnight continuous positive airway pressure were continued.

Round 2

Reviewer 3 Report

Thank you for your revisions to date that have somewhat improved the illustration of this key outcome

Unfortunately, there are still many errors of grammar, word usage and language: these should all be corrected. 

Whilst I fully appreciate that the word lancinating was listed in medical dictionary published almost 50 years ago, it is not now in standard use. The language used in this work should reflect current usage and ensure optimal clarity and readability

I note that the FOB levels were employed, have standard markers of inflammation (e.g. calprotectin) were not provided. FOB is not a standard tool to quantitate gut inflammation

Author Response

Thank you very much for reviewing our paper.

1. We submitted two papers last month to this journal, Gastrointestinal Disorders. Nobody marked “extensive editing of English language and style required” among seven reviewers except you. Our manuscripts are first checked for spelling, grammar, and expression using by a software program and then edited by a professional editor who is a native English speaker. We have published 36 papers in the past 10 years in various journals listed in PubMed. Reviewers have never required extensive editing of English language and style during the process of publication.

2. I have replaced the word lancinating with stabbing.

he felt mild stabbing pain

3. C-reactive protein is a standard biomarker in ulcerative colitis, but C-reactive protein is usually normal in mild cases. In a cases without macroscopic bloody stool, it is reasonable to check for fecal occult blood by means of fecal immunochemical test (FIT). In our case, C-reactive protein was normal and macroscopic bloody stool was absent; therefore, fecal occult blood was examined. Both FIT and fecal calprotectin are useful for monitoring/quantitating gut inflammation, as reported in the following articles.

Dai C, et al. Fecal immunochemical test for predicting mucosal healing in ulcerative colitis patients: a systemic review and meta-analysis. J Gastroenterol Hepatol 2018;33:990-997

Takashima S, et al. Evaluation of mucosal healing in ulcerative colitis by fecal calprotectin vs fecal immunochemical test. Am J Gastroenterol 2015;110:873-880

Round 3

Reviewer 3 Report

Thank you for your revision