Title: Association between obesity and Cervical Intraepithelial Neoplasia: Results from a case
control study in south western Uganda
Version: 1 Date: 24 Feb 2023
Reviewer's report:
Dear Authors,
Thank you for your manuscript that I read with great interest. Your manuscript is well written
and easy to follow to the point that gave me the opportunity to revise it within a very short delay.
As you rightly point out, the burden of cervical cancer is unacceptably high in Africa, therefore
all knowledge that is brought to better understanding the etiology is welcome, therefore the
relevance of your study.
However, your manuscript, in my opinion, can be improved in various way. Please, see below
my proposals to improve it.
General points of improvement:
- Define (possibly in the background or in the methods section) the definition of Central and
General Obesity
- In the background section, you speak about methods for preventing cervical cancer; it would be
good to include HPV vaccination, sexual education, and other methods with relevant references
- You calculated the requested sample size, which is a good practice; you even increased it
compared to the results you got from the software. However, given the number of variables for
which you may have adjusted your regression model(s), you may still have failed to find relevant/
significant association(s). Since your tables reporting the results from the logistic regression do
not report for which variable(s) you adjusted, I propose that you revise the analysis and include
in your model only the variables that "improve" the model; you can do this with the Likelihood
Ratio Test. Then, report in a footnote for each table which variables were included in the model
and the test you used to calculate the p-value (you did this for the other tables, but not for those
reporting the result of the regression). You may need to explain your strategy for multivariable
regression model in the methods section (i.e. line 129).
- Your Discussion section does not include a subsection on "strengths and limitation". Such
a subsection should come before the chapter on Conclusions. Indeed, by analysing what are
the limitations of your study, you will be able to put forward recommendations. Among the
limitations of your study, there is the limited sample size (see my point above) which may have
hidden associations that could have been visible with a higher sample. Another limitation is that
you did not account for vaccination against HPV (since the data collection is relatively recent,
would you be available to collect this information from the participants?); you highlight that
participants living in a particular area are generally wealthier, therefore probably more likely to
be vaccinated against HPV, a protective factor against cervical cancer. I propose you critically
think of your study, and you will probably find other limitations.
- I found it curious that you perform a regression analysis to see the factors associated with
obesity, but you do not the same for factors associated with cervical cancer (apart from obesity)
- your table 5. In fact, your outcome of interest is CIN, and obesity is the main exposure of
interest (not the outcome). I propose you include these possible factors in table 6.
- Once you have identified other possible limitations of your study, in the conclusion section you
may want to advance some recommendations on strategies in the fight against cervical cancer.
Another minor point is on line 121-123: QUOTE  "We then categorized BMI as non-obese (# 30
kg/m2) or obese (# 30 kg/m2) in accordance with standard cut off points." Therefore, according
to this statement, a possible participant with a precise BMI of 30 will be categorized as both
obese and non-obese. Moreover, please include a reference for the standard BMI cutoffs.
I wish you well for the revision of your manuscript.