Reply. Beyond the plate: exploring the complexities of using dietary approaches to manage endometriosis

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Sir, We thank Dr Rao et al. (2024) for their compliments on our study titled ‘The effect of dietary interventions on pain and quality of life in women diagnosed with endometriosis: a prospective study with control group’ (van Haaps et al., 2023) as well as for their knowledgeable comments (Rao et al., 2024). We have carefully considered their comments, one of which was that we did not investigate or exclude other self-management strategies, such as the use of CBD oil but also yoga and relaxation exercises. While some studies have suggested the effectiveness of yoga in managing endometriosis-related symptoms and quality of life (QoL) (Goncalves et al., 2016; Armour et al., 2019) found that yoga was inferior for endometriosis management, when compared to dietary interventions. Therefore, our main research focus was specifically set on dietary interventions. While we decided not to include other self-management strategies in our article, we did ask the participants about them. In our study, only 4 out of 43 participants applying a dietary intervention did yoga, while 1 out of 43 participants did Pilates. Regarding the use of CBD oil or cannabis only 1 out of 62 participants, positioned in our control group, used cannabis 3 times a week to improve sleep. None of the participants used CBD oil. Since these numbers are very small, they were considered non-confounding factors and were not included in our article. Therefore, we do not consider them to limit validity. Furthermore, we thank Dr Bashir et al. for acknowledging our thorough approach aimed at optimizing dietary adherence. However, we respectfully disagree with their assertion that the 3-day food diary does not provide a comprehensive picture of our participants’ eating habits, citing potential recall bias. To address this concern, we asked all participants to complete their food diary promptly after each meal. Furthermore, their food diaries were put in the ‘Eetmeter’. This is a tool that is developed by and can be found on the website of the Dutch Nutrition Center, which is funded by the Dutch Government. This broadly accepted tool allows dieticians to objectify current nutritional habits, ensuring a precise evaluation of the participants’ nutrient intake and identification of potential deficiencies to ensure a full-fledged diet. Consequently, we are confident that we have obtained a thorough understanding of our participants’ eating patterns. In addition, we agree with Dr Bashir et al. that the implication of digital tools, for example those developed by Chung et al, (2019) could be contributory. However, we would advocate for caution and offer a non-digital alternative as well. This is because relying solely on digital tools may introduce inequality, not only in a research population but also in a general population wanting to apply a dietary intervention. Not everyone has the ability to use technology either due to financial limitations or to a low educational level or cognitive disability. Moreover, written information, unlike information conveyed verbally, can be interpreted differently among individuals. Finally, it is possible that participants will not keep track of a digital tool consistently, e.g. a food diary, because it is not in their sight continuously. Therefore, we would recommend a balanced approach that considers both digital and non-digital tools as essential. Finally, we wholeheartedly agree with the point of Dr Bashir et al. regarding the importance of investigating and addressing significant barriers to adhere to a dietary intervention. We find their suggestion to involve the service industry particularly interesting, as minor modifications, such as incorporating markings on restaurant menus, could prove highly beneficial in enhancing the practicality of dietary adherence. While we addressed the difficulties shortly in our manuscript, future studies could be designed to map the difficulties in greater detail. None declared.

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