Review for 10.1186/s12876-025-04073-w (2025)

Title: Evaluation of the risk level for celiac disease among adults in semi-rural and urban areas
(Moungo and Wouri) in Cameroon: a questionnaire based study
Version: 2 Date: 04 Mar 2025
Reviewer:  Vaidehi Ulaganathan
Reviewer's report:
Abstract:
Grammar & Clarity:
"This study was therefore design to assess..." # should be "This study was therefore designed
to assess..."
"For this purpose, an epidemiological cross-sectional descriptive study targeted individuals over
18 who visited main district hospitals." # Consider rewording for clarity, e.g., "A cross-sectional
descriptive study was conducted among individuals over 18 who visited district hospitals."
Results Interpretation:
The transition from moderate to high risk is emphasized, but the magnitude of urban living
influence (3.60E+13) seems unusually high and should be reviewed for accuracy or clearer
explanation.
The contrast between urban and semi-rural participants could be more clearly contextualized—
why such a stark difference?
Conclusions & Recommendations:
The recommendation for "proper diagnostics" is valid but could be more specific—suggesting
serological testing, endoscopy, or further epidemiological studies would enhance this section.
INTRODUCTION
• While the background is informative, the discussion lacks specificity regarding celiac disease
in Cameroon. Given that the study is focused on Moungo and Wouri, it would be beneficial to
highlight any available data on celiac disease in Cameroon (even if limited). If no data exist,
this gap should be explicitly stated.
• The introduction moves from a global perspective to Africa but does not adequately set the
stage for why Cameroon is relevant in this discussion.
• Provide a brief summary of any known prevalence studies or gastrointestinal health issues in
Cameroon to create a stronger connection between the global issue and the local study.
• The study gap should be more explicitly stated in one or two concise sentences, rather than
being scattered throughout different sections.
• The gap between existing global knowledge and the local context (Cameroon) is not
sufficiently emphasized.
• Clearly state that no studies have assessed the risk of celiac disease in Cameroon using self-
reported questionnaires, which makes this research novel and necessary.
• The problem statement is not clearly distinguished from the background. The transition from
discussing celiac disease at a global level to focusing on Cameroon is not seamless—there needs
to be a stronger link between the general problem and the specific research focus.
• Clearly articulate the problem in a few sentences: "Despite the increasing prevalence of celiac
disease globally, it remains underdiagnosed in Cameroon. Limited awareness, lack of diagnostic
resources, and disparities between urban and semi-rural areas contribute to this issue. This study
aims to bridge this gap by assessing the risk of celiac disease among adults in Moungo and
Wouri using self-reported questionnaires."
• Several references are cited, including both recent (2022, 2024) and older (2015, 2009) sources,
showing a mix of historical and contemporary research.
• The inclusion of studies on prevalence, diagnostic tools, and health disparities strengthens the
foundation of the study.
• Ensure that "(Celiac Disease Foundation, Celiac Australia)" is formatted properly—if these
are organizations rather than authors, use appropriate citation style (e.g., mention them in-text
without parentheses or use institutional citation format).
• A full reference list is not provided—ensure that all sources cited in the text are included in
the reference list.
• Some sentences are overly complex, making readability difficult.
• Minor grammatical errors exist (e.g., "The works of El Badmoussi (2022) and Makharia et al.
(2022) reveal that notable differences exist between rural and urban areas, with several studies
indicating that celiac disease is generally more common in urban settings." # could be reworded
for better flow).
• Use of "mastering such information" is awkward—perhaps "Understanding these factors"
would be clearer.
• Break long sentences into shorter, clearer ones.
• Ensure consistency in verb tenses and phrasing.
• Avoid redundancy—certain points (e.g., underdiagnosis, rural-urban differences) are repeated
multiple times in slightly different ways.
DISCUSSION
• Some statements lack clarity due to awkward phrasing and grammatical inconsistencies. For
example:
o “The study was based on survey, it could explain why the prevalence could of these symptoms
could be high in urban area.” # Reword: "Since the study relied on self-reported data, this may
explain why symptom prevalence appears higher in urban areas."
o “The semi-rural area is characterized by low and moderate risk levels, while the urban area
predisposes individuals to high risk regarding celiac disease.” # Reword: "Individuals in semi-
rural areas exhibited lower to moderate risk levels, whereas those in urban areas had a higher
risk of celiac disease."
• The discussion of dietary patterns (wheat consumption) should explicitly address whether
cultural differences or economic constraints drive these patterns in Cameroon.
• Improve transitions between paragraphs for better flow. The shift from symptoms to dietary
practices, for example, is abrupt. A bridging sentence would help maintain coherence.
• Clarify the implication of the findings. Does this mean urban areas should focus more on
gluten-free dietary awareness? Should semi-rural areas improve their healthcare accessibility?
• The discussion needs a stronger acknowledgment of study limitations. The reliance on self-
reported data is mentioned, but biases like recall bias or social desirability bias should be
explicitly acknowledged.
• The statement “Although the risk levels identified in this study may not accurately reflect the
actual occurrence of the disease…” is good but should be further expanded to acknowledge that
self-reported symptoms are not a definitive diagnosis.
• Explicitly state that biomarker-based studies or clinical diagnosis methods would be necessary
to confirm these risk levels.
• Strengthen the comparison with Lebwohl & Rubio-Tapia (2021) and Lexner et al. (2024) by
explaining why Cameroon’s context differs from European studies.
• Add a sentence discussing the implications for public health policies—for example, should
Cameroon integrate gluten awareness campaigns or improve diagnostic tools?
• The discussion should clearly distinguish correlation from causation. Some statements imply
a direct link between risk factors and disease, whereas this is a risk assessment study, not a
clinical diagnosis.
• For example, "frequent consumption of wheat bread, wheat cakes, beer, and residence in urban
areas are also significant risk factors for this condition.”
o This should be reworded to: "Frequent consumption of wheat-based products and residence
in urban areas were associated with a higher risk score for celiac disease, suggesting a potential
link that warrants further investigation."
• The conclusion should briefly reiterate the study’s major contribution: the use of self-reported
questionnaires to estimate celiac disease risk in Cameroon.
• Instead of stating “urgent confirmation studies are needed…”, specify what kind of studies
should be conducted (e.g., serological testing, biopsy confirmation, larger epidemiological
surveys)."This study provides preliminary insights into the potential burden of celiac disease
in Cameroon and highlights significant disparities in risk levels between urban and semi-rural
populations. Future studies utilizing serological testing and biopsy confirmation are necessary
to establish the true prevalence of celiac disease in the country."
GENERAL COMMENT
Grammar & Sentence Structure Issues
Some sentences are too long and complex, making them difficult to follow. Example:
“Since the study was based on survey, it could explain why the prevalence could of these
symptoms could be high in urban area.”
Correction: "Since the study relied on self-reported data, this may explain why symptom
prevalence appeared higher in urban areas."
Subject-verb agreement errors:
“These observations contradict the findings of Lebwohl & Rubio-Tapia, (2021) and Lexner et
al., (2024), which indicate that the prevalence of celiac disease is not influenced by locality in
Europe.”
Correction: “…who indicate that celiac disease prevalence is not influenced by locality in
Europe.” (Use who for authors, not which).
Spelling & Typographical Errors
“National institute of statistics” # should be “National Institute of Statistics” (capitalize
properly).
“The prevalence could of these symptoms could be high in urban area” # should be “…the
prevalence of these symptoms could be high in urban areas.”
“a limited access to animal protein sources” # should be “limited access to animal protein
sources” (remove unnecessary article a).
Word Choice & Redundancies
Some words are repeated unnecessarily, making sentences awkward:
"The study does not claim to establish a diagnostic framework for celiac disease, but its
conclusions offer valuable insights of the potential distribution of the disease in the littoral region
of Cameroon."
Correction: "Although this study does not provide a diagnostic framework for celiac disease, it
offers valuable insights into its potential distribution in the Littoral region of Cameroon."
"This discrepancy may stem from the relatively uniform healthcare facilities available in both
urban and rural areas across most European countries, unlike the situation in Cameroon."
Correction: "This discrepancy may be due to more uniform healthcare facilities in Europe
compared to Cameroon." (More concise).
Proofread carefully for grammar, spelling, and sentence structure.
Simplify long or redundant sentences to enhance clarity.
Use more precise and concise phrasing for a smoother academic flow.