The Evidence-Based Instrument for the Nutritional Assessment of Individuals with Autism Spectrum Disorder
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe merits and significance of this manuscript are apparent. However, the lack of clarity and organization in the writing of the manuscript do not make the thesis of their work stand out. For more specific context, a lot of the details in the discussion that talk about the feeding difficulties that individuals with ASD face (Lines 257-285; Lines 295-300) should actually be in the introduction of the manuscript. The point of the introduction is to describe what is known, unknown, state the research goal/question of the paper, and give an overview of what the paper will show. The discussion needs to state the results and what the outcomes found suggest outside of the research contexts. Then there should be some statements to talk about the limitations of these findings which the authors have made a separate section for. It needs to be made clear that this is a paper that validates its usefulness among experts and not an implementation of the assessment with the ASD population. Part of making sure that clarity is there is not only define ASD and food-related difficulties in ASD in the introduction, but also defining the Delphi method and the defining why you need to validate it by experts in the first place.
Author Response
We would like to sincerely thank the reviewer for their valuable comments and suggestions. Their feedback was very helpful and contributed to improving the quality and clarity of our manuscript.
Reviewer #1:
The lack of clarity and organization in the writing of the manuscript do not make the thesis of their work stand out. For more specific context, a lot of the details in the discussion that talk about the feeding difficulties that individuals with ASD face (Lines 257-285; Lines 295-300) should actually be in the introductions of the manuscript. The point of the introduction is to describe what is known, unknown, state the research goal/question of the paper, and give an overview of what the paper will show.
Answer: Thank you for your suggestion. We carefully revised the discussion and introduction session. We included relevant information to improve the clarity and organization of the study’s purpose, providing the reader with an overview of what the nutritional assessment instrument for individuals with ASD covers. The changes in the manuscript are highlighted (Lines 52–71; Lines 92–108; Lines 122–143).
The discussion needs to state the results and what the outcomes found suggest outside of the research contexts.
Answer: Thank you for your comment. We have revised the Discussion section to explicitly highlight the study's findings and their broader implications beyond the research context. In particular, we emphasize how the instrument fills a critical gap in clinical practice by facilitating the early identification of feeding and nutritional issues in individuals with ASD and supporting the development of targeted interventions to improve outcomes. These revisions are reflected in lines 454–457.
Then there should be some statements to talk about the limitations of the findings which the authors have made a separate section for. It needs to be made clear that this is a paper that validates its usefulness among experts and not implementations of the assessment with the ASD population.
Answer: Thank you for this valuable observation. We have revised the Limitations section (Lines 461–465) to explicitly address the scope and constraints of our findings. In particular, we clarify that the present study focuses on validating the instrument’s content through expert evaluation and does not include its implementation or testing with individuals from the ASD population. We also highlight the need for future research to evaluate the instrument’s practical application, including its psychometric properties, such as test-retest reliability, construct validity, and cultural adaptability, in order to establish its clinical utility.
Part of making sure that clarity is there is not only define ASD and food-related difficulties in ASD in the introduction, but also defining the Delphi method and the defining why you need to validate it by experts in the first place.
Answer: Thank you for this important observation. In response, we revised the Introduction section (Lines 122–143) to provide a clearer definition of the study objective and the rationale for expert validation at this stage of development. We also explicitly explained why the Delphi method was chosen, highlighting it as a structured and iterative expert consensus technique, widely used in healthcare research for instrument development when empirical data on the target population are limited. These changes ensure that the reader understands both the necessity of expert involvement and the methodological appropriateness of using a modified Delphi approach for content validation of the proposed instrument.
Reviewer 2 Report
Comments and Suggestions for AuthorsIt is necessary to more clearly define the research objective and how this instrument differentiates itself from existing tools. While the tool is described as an assessment of the nutritional status of individuals with ASD, it remains ambiguous whether the focus is on nutritional status per se or on behavioral issues related to feeding. In the introduction, the emphasis appears to lean more toward feeding-related behavioral disturbances.
Additionally, although the manuscript mentions the need for a comprehensive and valid assessment tool, it would be beneficial to specify in more concrete terms which aspects of nutrition the instrument intends to evaluate. If the tool includes components assessing nutritional status, the introduction should address how the nutritional status of individuals with ASD differs from that of neurotypical individuals. In such a case, highlighting deficiencies in specific nutrients or areas requiring nutritional supplementation would strengthen the rationale.
Furthermore, the tool has not undergone a formal validation process. Cultural adaptability, practical feasibility, and test-retest reliability have yet to be examined. It is essential to explicitly state that future studies must include applications with actual patients and rigorous analyses of the tool’s validity and reliability.
Author Response
We would like to sincerely thank the reviewer for their valuable comments and suggestions. Their feedback was very helpful and contributed to improving the quality and clarity of our manuscript.
Reviewer #2:
It is necessary to more clearly define the research objective and how this instrument differentiates itself from existing tools. While the tool is described as an assessment of the nutritional status of individuals with ASD, it remains ambiguous whether the focus is on nutritional status per se or on behavioral issues related to feeding. In the introduction, the emphasis appears to lean more toward feeding-related behavioral disturbances.
Answer: Thank you for this important comment. We have revised the Introduction section to more clearly define the research objective and to clarify the unique scope of the proposed instrument. Rather than focusing exclusively on nutritional status or feeding-related behavioral challenges, the instrument was designed to provide a comprehensive assessment of the individual’s overall nutritional profile. This includes clinical, behavioral, physiological, and socioeconomic dimensions that may impact nutrition in individuals with ASD.
We emphasize that effective nutritional interventions require a detailed and multidimensional understanding of the factors influencing nutritional health. In many cases, challenges related to feeding and nutrition stem from the interaction of multiple domains, such as behavioral rigidity, gastrointestinal symptoms, and environmental or social conditions, underscoring the need for an integrated approach. To our knowledge, there is currently no gold-standard tool that addresses this complexity specifically for the ASD population.
Our instrument was developed to fill this gap, enabling clinicians to identify and interpret a wide range of factors that may compromise nutrition and to guide individualized, evidence-based interventions. These clarifications and additions are reflected in the revised manuscript (Lines 52–71; 92–108; 122–143).
Although the manuscript mentions the need for a comprehensive and valid assessment tool, it would be beneficial to specify in more concrete terms which aspects of nutrition the instrument intends to evaluate. If the tool includes components assessing nutritional status, the introduction should address how the nutritional status of individuals with ASD differs from that of neurotypical individuals. In such a case, highlighting deficiencies in specific nutrients or areas requiring nutritional supplementation would strengthen the rationale.
Answer: Thank you for your valuable comment. We have revised the Introduction (Lines 92–108) to more explicitly describe the specific nutritional aspects assessed by the instrument. The manuscript now details how the nutritional status of individuals with ASD often differs from that of neurotypical individuals, emphasizing documented deficiencies in key nutrients such as calcium, vitamin D, and omega-3 fatty acids, as well as potential needs for supplementation. We also clarify that nutritional inadequacies in individuals with ASD are frequently multifactorial in origin. For example, feeding difficulties, such as food selectivity, sensory sensitivities, and rigid eating behaviors, can significantly limit dietary variety and intake, leading to an inadequate nutritional status and imbalances in both macro- and micronutrient levels. These factors reinforce the need for a comprehensive tool capable of capturing the full range of clinical, behavioral, and dietary contributors to nutritional health. This clarification strengthens the rationale for the instrument’s broad, integrative scope.
The tool has not undergone a formal validation process. Cultural adaptability, practical feasibility, and test-retest reliability have yet to be examined. It is essential to explicitly state that future studies must include applications with actual patients and rigorous analysis of the tool’s validity and reliability.
Answer: Thank you for your important comment. We have revised the Limitations section (Lines 461–465) to explicitly acknowledge that the instrument has not yet undergone a formal validation process. Specifically, we state that key aspects, such as cultural adaptability, practical feasibility, and test-retest reliability, remain to be investigated. We also emphasize the need for future studies to apply the tool in clinical settings with individuals diagnosed with ASD and to conduct rigorous analyses of its psychometric properties, including validity and reliability. These additions underscore the preliminary nature of the current study and the critical steps required to confirm the instrument’s utility in practice.
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsThe current version has drastically improved. I only have two minor issues with how the discussion is written:
- Some of the phrasing makes it sound like the assessment had not been fully realized. The first paragraph of the discussion establishes very well that there is no suitable tool to assess ASD and nutritional difficulties. My suggestion from lines 279 onwards is to go through each section of the instrument to explicitly describe the purpose of the original design of each section and how the feedback from the experts improved the design. The greater impact then could be what is still important to address in the assessment with the information that can or cannot be gathered with the instrument.
- The second issue ties in with what I ended up feeling after trying to read through the discussion. There is a lot of detail with all the possible factors that could influence the nutritional difficulties in ASD. It would be a more impactful discussion to discuss the practical implications of your instrument rather than discuss all the factors that can be attributed to nutritional difficulties in ASD. If there was a clear organization of the discussion like it is on the instrument, then I think your manuscript will be even more impactful.
Author Response
Letter Reply
Manuscript ID: dietetics-3705226
The Evidence-Based Instrument for the Nutritional Assessment of Individuals with Autism Spectrum Disorder
Dear Editor,
Thank you for your thoughtful and constructive feedback on our manuscript. We sincerely appreciate your careful reading and valuable suggestions, which have helped us improve the clarity, focus, and overall impact of the discussion section. More specifically, we restructured the discussion to align more closely with the organization of the instrument, presenting each domain in sequence and explaining its purpose and the impact of expert feedback on its refinement. This approach ensures a clearer narrative regarding the development process and the rationale behind each component of the tool.
Below, we provide a detailed response. In addition, the revised version of the manuscript, with all changes clearly highlighted, has been submitted.
Respectfully,
Rudimar Riesgo – corresponding author
On behalf all authors
Answer to reviewers:
Thank you very much for your valuable and constructive feedback. We appreciate your positive assessment of the revised version and are grateful for your thoughtful suggestions regarding the Discussion section. Below, we address each of your comments point by point and describe the changes made accordingly.
- Some of the phrasing makes it sound like the assessment had not been fully realized. The first paragraph of the discussion establishes very well that there is no suitable tool to assess ASD and nutritional difficulties. My suggestion from lines 279 onwards is to go through each section of the instrument to explicitly describe the purpose of the original design of each section and how the feedback from the experts improved the design. The greater impact than could be what is still important to address in the assessment with the information that can or cannot be gathered with the instrument.
- The second issue ties in with what I ended up feeling after trying to read through the discussion. There is a lot of detail with all the possible factors that could influence the nutritional difficulties in ASD. It would be a more impactful discussion to discuss the practical implications of your instrument rather than discuss all the factors that can be attributed to nutritional difficulties in ASD. If there was a clear organization of the discussion like it is on the instrument, then I think your manuscript will be even more impactful.
We understand your concern regarding the phrasing that may have suggested the assessment was not fully realized. To address this, we have revised the discussion to more clearly articulate that the instrument was developed with a solid foundation based on existing literature and clinical needs, and that expert feedback served to enhance and refine each domain. Following your suggestion, we have now reorganized the discussion to systematically go through each section of the instrument. For each domain, we describe its original purpose and explain how the expert contributions improved its structure, scope, or focus. This change provides a clearer narrative about the development process and highlights the intentional design of the tool.
We acknowledge that the original version of the discussion included extensive detail about the potential factors influencing nutritional difficulties in individuals with ASD, which may have diluted the practical impact of the findings. In response, we have streamlined this section to focus more directly on the practical applications of the instrument in clinical settings. The revised discussion highlights how the tool can support clinical decision-making, guide individualized care plans, and be applied in both initial assessments and longitudinal monitoring. We believe this adjustment makes the discussion more relevant and impactful for practitioners and researchers alike.
Following your insightful recommendation, we have restructured the discussion to mirror the organization of the instrument itself. This alignment improves the coherence of the text and facilitates a clearer understanding of how each domain contributes to the overall assessment. We agree that this structure enhances the manuscript’s clarity and strengthens the presentation of the instrument’s utility.
Once again, thank you for your valuable feedback. Your suggestions have significantly contributed to improving the manuscript, and we are confident that the revised version presents a clearer, more focused, and clinically relevant discussion.
Reviewer 2 Report
Comments and Suggestions for AuthorsYour detailed responses to the reviewers’ comments are greatly appreciated.
Author Response
Letter Reply
Manuscript ID: dietetics-3705226
The Evidence-Based Instrument for the Nutritional Assessment of Individuals with Autism Spectrum Disorder
Dear Editor,
Thank you for your thoughtful and constructive feedback on our manuscript. We sincerely appreciate your careful reading and valuable suggestions, which have helped us improve the clarity, focus, and overall impact of the discussion section. More specifically, we restructured the discussion to align more closely with the organization of the instrument, presenting each domain in sequence and explaining its purpose and the impact of expert feedback on its refinement. This approach ensures a clearer narrative regarding the development process and the rationale behind each component of the tool.
Below, we provide a detailed response. In addition, the revised version of the manuscript, with all changes clearly highlighted, has been submitted.
Respectfully,
Rudimar Riesgo – corresponding author
On behalf all authors
Answer to reviewers:
Thank you very much for your valuable and constructive feedback. We appreciate your positive assessment of the revised version and are grateful for your thoughtful suggestions regarding the Discussion section. Below, we address each of your comments point by point and describe the changes made accordingly.
- Some of the phrasing makes it sound like the assessment had not been fully realized. The first paragraph of the discussion establishes very well that there is no suitable tool to assess ASD and nutritional difficulties. My suggestion from lines 279 onwards is to go through each section of the instrument to explicitly describe the purpose of the original design of each section and how the feedback from the experts improved the design. The greater impact than could be what is still important to address in the assessment with the information that can or cannot be gathered with the instrument.
- The second issue ties in with what I ended up feeling after trying to read through the discussion. There is a lot of detail with all the possible factors that could influence the nutritional difficulties in ASD. It would be a more impactful discussion to discuss the practical implications of your instrument rather than discuss all the factors that can be attributed to nutritional difficulties in ASD. If there was a clear organization of the discussion like it is on the instrument, then I think your manuscript will be even more impactful.
We understand your concern regarding the phrasing that may have suggested the assessment was not fully realized. To address this, we have revised the discussion to more clearly articulate that the instrument was developed with a solid foundation based on existing literature and clinical needs, and that expert feedback served to enhance and refine each domain. Following your suggestion, we have now reorganized the discussion to systematically go through each section of the instrument. For each domain, we describe its original purpose and explain how the expert contributions improved its structure, scope, or focus. This change provides a clearer narrative about the development process and highlights the intentional design of the tool.
We acknowledge that the original version of the discussion included extensive detail about the potential factors influencing nutritional difficulties in individuals with ASD, which may have diluted the practical impact of the findings. In response, we have streamlined this section to focus more directly on the practical applications of the instrument in clinical settings. The revised discussion highlights how the tool can support clinical decision-making, guide individualized care plans, and be applied in both initial assessments and longitudinal monitoring. We believe this adjustment makes the discussion more relevant and impactful for practitioners and researchers alike.
Following your insightful recommendation, we have restructured the discussion to mirror the organization of the instrument itself. This alignment improves the coherence of the text and facilitates a clearer understanding of how each domain contributes to the overall assessment. We agree that this structure enhances the manuscript’s clarity and strengthens the presentation of the instrument’s utility.
Once again, thank you for your valuable feedback. Your suggestions have significantly contributed to improving the manuscript, and we are confident that the revised version presents a clearer, more focused, and clinically relevant discussion.
