An Irish Multi-Centre Study of Behaviours, Attitudes and Barriers to Exercise in Inflammatory Bowel Disease, a Survey from the Patient’s Perspective
Round 1
Reviewer 1 Report
Thank you for submitting this interesting work which I am sure will help mould your interesting future study.
The numbers of patients included is impressive.
However there are some major flaws with this study that are not discussed in enough detail.
You used a non validated questionnaire and do not seem to have involved any methodologist trained in survey design to avoid leading questions etc.. You rely on patient recall of what their exercise frequency was before diagnosis. However no information on duration of disease. Patient recall only as a measurement of how much exercise they do is not very reliable yet this not mentioned in the paper.
No attempt to do any measurements of sarcopaenia etc made in this study.
Your title says barriers to exercise but were patients asked about barriers such as financial/geographical/work and social responsibilities that may have also impact on patients ability to exercise ?
Scatterplot figure 3 - unclear what each dot represents . If each dot= patient -why are there so few patients included in this ?
The data you report on weight is very weak as (pointed out) you don't have height to do BMI and is self reported only.
I am not sure why your discussion comes before materials/methods? Seems more sensible to more to end of paper.
Author Response
Response to Reviewer Comments 1
The authors would like to thank Reviewer 1 for their time and valuable comens.
Point 1: You used a non validated questionnaire and do not seem to have involved any methodologist trained in survey design to avoid leading questions etc.. You rely on patient recall of what their exercise frequency was before diagnosis. However no information on duration of disease. Patient recall only as a measurement of how much exercise they do is not very reliable yet this not mentioned in the paper.
Response 1: We reviewed the literature prior to creating our questionnaire to include the most relevant questions with the specific aim to inform us of our own patient behaviours, needs and wants prior to embarking on a feasibility study examining the effects of supervised exercise in patients with active disease
We acknowledge the risk of recall bias using a survey and have included this in our discussion as follows- “The reliance on participant recall through the medium of a survey may lead to inaccurate reporting by participants. However, the simple ‘yes’ or ‘no’ nature of the response to the change in exercise behavior before and after diagnosis did not require a significant level of detail to recall which potentially reduced the participants inaccuracy in their account”.
Point 2: No attempt to do any measurements of sarcopaenia etc made in this study.
Response 2: Sarcopenia is defined by low muscle mass, poor muscle strength and function. The authors felt it would be very difficult to measure these parameters by means of a questionnaire and aim to include these measurements as part of the feasibility study.
Point 3: Your title says barriers to exercise but were patients asked about barriers such as financial/geographical/work and social responsibilities that may have also impact on patients ability to exercise ?
Response 3: These barriers were not included, we decided to focus on disease-specific barriers rather than more general barriers. Of note our exercise programme as part of the feasibility study is fully funded for participants so monetary barriers were not a priority for the survey. Additionally, our exercise programme is available online hence the focus remained on disease-specific barriers.
Point 4: Scatterplot figure 3 - unclear what each dot represents . If each dot= patient -why are there so few patients included in this ?
Response 4: Dot=pair result, multiple patients reported same importance of exercise and same number of exercise days, total responses for both are 193 patients, this has been updated in the legend.
Point 5: The data you report on weight is very weak as (pointed out) you don't have height to do BMI and is self-reported only.
Response 5: Our main aim of the survey was to gain a better understanding of our patients exercise habits and barriers to exercise therefore we had excluded height as the focus was not on body anthropometrics. We however, acknowledge that a review of BMI would have been relevant to the current findings but we are including anthropometrics and more detailed body composition measurements as part of our ongoing feasibility study.
Point 6: I am not sure why your discussion comes before materials/methods? Seems more sensible to more to end of paper.
Response 6: This is due to the format advised by the journal, the authors are more than happy to change the order if approved by the editors.
Reviewer 2 Report
I appreciate the opportunity to review this interesting paper on behaviours, attitudes and barriers to exercise in IBD.
This paper determined the prevalence of exercise in two hundred and seven patients with IBD and their limitations secondary to their disease. The authors additionally assessed the presence of body image dissatisfaction in IBD patients. Subjects completed the survey with questions related to body image, willingness to receive personalised exercise advice and willingness to participate in a physician-supervised exercise programme.
Among limiting barriers and conditions were fatigue followed by luminal symptoms, toilet concerns, joint pains and a lack of time. The authors concluded that IBD patients are receptive to personalised exercise advice. The author's conclusions warrant future studies on this subject.
I commend the authors for several strengths of their work, including addressing an interesting and timely question, careful planning and design of the study, and well-performed analysis.
The subject is in the range of the journal, and the manuscript is of clinical relevance. It is well written, and the data are appropriately presented.
Considering these strengths, though, as I read the manuscript, I found some areas in which I would have appreciated greater clarity.
· The main problem hindering the evaluation is the lack of access to the questionnaire. I understand from the text that one will be available to the reader.
· I consider it a strength of the present study that the authors researched body image dissatisfaction in IBD patients. However, what is lacking is a justification for taking up this problem in the introduction and a factual analysis of the obtained results in the discussion. For a reader unfamiliar with the problem, it will be unclear why the authors took up the issue.
· Reading the paper made me think of a similar study conducted a few years ago (DeFilippis et al., 2016). The authors put this paper in the bibliography but nowhere in the text do they refer to it.
· The aforementioned paper (DeFilippis et al., 2016) distinguished between "fatigue" and "weakness." This seems to be a reasonable approach. IBD patients, especially those with CD, may have a reduction in skeletal muscle mass, which may contribute to, but is not the sole cause of fatigue. Have the authors of this paper studied this problem?
· It is incomprehensible why the authors did not assess at least BMI in the study participants. They admit that it is a limitation but why did they not include a question about height in the questionnaire?
Minor
· In the abstract, instead of the phrase "lack of energy" it is better to use the word "fatigue" because this is what the authors studied.
DEFILIPPIS, E. M., TABANI, S., WARREN, R. U., CHRISTOS, P. J., BOSWORTH, B. P. & SCHERL, E. J. 2016. Exercise and Self-Reported Limitations in Patients with Inflammatory Bowel Disease. Dig Dis Sci, 61, 215-20.
Author Response
Response to Reviewer 2
The authors would like to thank Reviewer 2 for their time and valuable comments.
Point 1: The main problem hindering the evaluation is the lack of access to the questionnaire. I understand from the text that one will be available to the reader.
Response 1: The questionnaire was submitted in the supplementary material along with the paper submission.
Point 2: I consider it a strength of the present study that the authors researched body image dissatisfaction in IBD patients. However, what is lacking is a justification for taking up this problem in the introduction and a factual analysis of the obtained results in the discussion. For a reader unfamiliar with the problem, it will be unclear why the authors took up the issue.
Response 2: The following in relation to body image dissatisfaction has been included in the introduction section: “Additionally, body image dissatisfaction is common amongst patients with IBD and is associated with a negative impact on quality of life [12, 13]. Fatigue, which is independently associated with body image dissatisfaction, has been shown to improve with exercise in existing studies. Hence, it is plausible that body image dissatisfaction may be improved with the use of exercise programmes also”.
-Discussion- "Finally, body image dissatisfaction was reported by two-thirds of survey respondents and were associated with female gender and younger age (< 45 years). Patients felt that engaging in regular physical activity could positively address the presence of body image concerns. Previous studies in adolescents have shown a relationship with body image dissatisfaction and lack of physical activity, however, this remains a poorly studied area despite its frequency in patients with chronic diseases [40-43]. In addition to a positive effect on body image, the majority of participants felt that exercise has the additional benefits of enhancing both physical wellness and psychological wellness (mood and anxiety). Further studies are required to understand the complex relationship of body image dissatisfaction and IBD".
-The authors would be happy to expand further on this, however the reason for the inclusion of body image concerns is as above due to its link with fatigue and the potential for exercise to positively impact on body image dissastisfaction. We have found that data are limited in adult patients with IBD and further studies are required to fully understand the relationship between IBD and body image dissatisfaction.
Point 3: Reading the paper made me think of a similar study conducted a few years ago (DeFilippis et al., 2016). The authors put this paper in the bibliography but nowhere in the text do they refer to it.
Response 3: We have referenced the study in the method section as it was reviewed by the authors as part of a literature review of pre-existing surveys on physical activity and exercise in patients with IBD which informed our current survey- “ The investigators designed a 19-question, two-page survey that takes 2-3 minutes to complete based on previous surveys on exercise and physical activity in IBD [17-22]”.
The study by DeFillipes is reference number 18.
Point 4: The aforementioned paper (DeFilippis et al., 2016) distinguished between "fatigue" and "weakness." This seems to be a reasonable approach. IBD patients, especially those with CD, may have a reduction in skeletal muscle mass, which may contribute to, but is not the sole cause of fatigue. Have the authors of this paper studied this problem?
Response 4: We are recording measurements of sarcopenia including hand-grip strength, sit-to stand, skeletal muscle mass as measured by bioelectrical impedance analysis, muscle thickness by anterior thigh US as part of the feasibility study referenced in the paper with reference to the study protocol- “This survey was carried out as a precursor to the development of a new referral pathway to a community-based physician-derived exercise programme and a feasibility randomised controlled exercise study on patients with moderate to severe IBD undergoing induction with disease-modifying therapies (Clinicaltrials.gov NCT05174754)”.
This study is currently recruiting and data will be reported in the future which includes measurement of fatigue levels and muscle mass, function and performance.
Point 5: It is incomprehensible why the authors did not assess at least BMI in the study participants. They admit that it is a limitation but why did they not include a question about height in the questionnaire?
Response 5: The height was omitted as to examine the relationship between body anthropometrics and exercise was not an aim of the current survey. We felt it was important when we had included weight to comment on the results and the trend toward a higher mean weight in our patient population however, our main focus was to examine the behaviours, attitudes and barriers to exercise to inform the investigators prior to recruitment for the exercise study.
Point 6: In the abstract, instead of the phrase "lack of energy" it is better to use the word "fatigue" because this is what the authors studied.
Response 6: This has been updated, we thank you for the recommendation.
Point 7: DEFILIPPIS, E. M., TABANI, S., WARREN, R. U., CHRISTOS, P. J., BOSWORTH, B. P. & SCHERL, E. J. 2016. Exercise and Self-Reported Limitations in Patients with Inflammatory Bowel Disease. Dig Dis Sci, 61, 215-20.
Response 7: We have referenced the study in the method section as it was reviewed by the authors as part of a literature review of pre-existing surveys on physical activity and exercise in patients with IBD which informed our current survey- “ The investigators designed a 19-question, two-page survey that takes 2-3 minutes to complete based on previous surveys on exercise and physical activity in IBD [17-22]”.
The study by DeFillipes is reference number 18.
Reviewer 3 Report
This is a nice study with results that led to subsequent action. It is of interest for other IBD centres that wish to improve the service provided to IBD patients. Congratulations to the authors.
Author Response
We thank Reviewer 3 for their positive feedback on our study.
Round 2
Reviewer 1 Report
Thank you for addressing the comments and make the suggested changes to the paper.
Reviewer 2 Report
The authors have addressed the majority of the concerns identified. My recommendation is to accept the article.
