Reviewer’s report
Title: 
The impact of symptoms on quality of life before and after diagnosis of
coeliac disease: the results from a Polish population survey and comparison with
the results from the United Kingdom
Version: 
1 
Date: 
07 Sep 2020
Reviewer's report:
General Comment 
The paper addresses relevant aspects of QoL in CD patients, in a comprehensive
population . Reported results are interesting as well as the comparison with a
similar British study which reveals important differences between both
populations. 
However there are some major issues to consider: 
How reliable is it to answer a survey related to an event years after the event has
occurred? In adult participants many years elapsed between diagnosis and the
survey concerning the Diagnosis period and the years before. Specifically how
reliable are data concerning consultations before the diagnosis . etc 
Similarly the lower change in EQ-Index in Polish coeliac respondents as
compare to UK could be related 
to QoL information given by parents and
children being less accurate as compared to the personal feeling refered by the
adult patient. In the British study as the cipher of <18y at dx was 
12% its impact
on the whole population 
is probably very low. In the polish serie , <18 y
represents 
exactly the same number as the 18-34 y subgroup , i.e . 282 ( 36.7%) 
These limitation needs to be addressed in the Discussion.
The pediatric population representing 36% of the study population the results of
this subgroup should be analysed separately and compared with data from adults
. This would give more reliable 
information on the characteristics of CD
diagnosis in Poland 
and give some clues on how to improve awareness and
earlier diagnosis. 
At least it is worthy to analyze this subgroup separately 
r parameters like ; 
Symptoms
Duration of symptoms before Dx 
Compliance with the GFD
Also comparing 
Diagnosed 
before and after the year 2000 
It would be also interesting to compare 
Diagnostic process in children versus
adults . This could support the view outed in the Discussion of 
CD being still
considered a pediatric disease in Poland in the late 90´s . 
Some specific comments 
Page 2 L 52 Many researchers have suggested that extra-intestinal symptoms are
increasingly frequently the only manifestation of CD, especially in older children
and adults. 
The writing leads to confusion . Please modify it 
Page 2 L 54 It has not been established whether this results from an increasing
incidence of non-classical CD, greater awareness in physicians and CD patients
(6), or more effective detection of CD in adults in recent years.
I suggest to modify the writing into: 
It has not been established whether this results from a true 
increasing incidence
of non-classical CD, or from 
greater awareness of physicians and CD patients
(6), or from 
more effective detection of CD in adults in recent years.
Page 3 L 3 : 
Reference is missing 
Page 3 L9 That finding, and suspicion that in Poland the mean time between the
onset of coeliac symptoms and CD diagnosis can be even longer than in the UK,
encouraged the authors of this study to conduct a similar study using comparable
instruments and methods among Polish CD patients.
I suggest to modify the writing into: 
That finding, and suspicion that in Poland the mean time between the onset of
coeliac symptoms and CD diagnosis could 
be even longer than in the UK 
lead us
to 
conduct a similar study using comparable instruments and methods among
Polish CD patients.
Page 3 L 7 Suspicion that in Poland the mean time between the onset of coeliac
symptoms and CD diagnosis can be even longer than in the UK, encouraged the
authors of this study to conduct a similar study using comparable instruments
and methods among Polish CD patients.
What was the rationale for this suspicion ?
Also it looks like the main aim is to compare the data from Poland to those of
the British study 
either than to learn about the specific situation in Poland . 
Page 4 L 22 respondents were asked to assess their quality of life at the time of
their diagnosis and at the time of the survey.
How reliable is to answer a survey related to the time of diagnosis 
years after the
diagnosis has been made . 
Are responses to Questions like Q8 
reliable ??
8. During the time that you had symptoms related to coeliac disease but had not
yet been diagnosed, approximately how many days did you take off work due to
your symptoms? 
Page 8 L17 : Polish answerers before CD diagnosis had more problems with
anxiety and depression (p<0.001) and self-care (p<0.002). 
I suggest to modify the writing into: 
Polish answerers 
had before CD diagnosis 
more problems with anxiety and
depression (p<0.001) and self-care (p<0.002).
Page 11 L 23-32 
Those results met with some disbelief among Polish clinicians, which
encouraged the authors of this study to conduct a similar analysis in Poland,
using a similar questionnaire and methods. 
A similar number of surveyees took part in the Polish and in the British study.
CD affects females more often than males and this was confirmed in both
studies, with a majority of females in each study group.
Publons Reviewer Recognition
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No
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no comepting interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Reviewer’s report
Title: 
The impact of symptoms on quality of life before and after diagnosis of
coeliac disease: the results from a Polish population survey and comparison with
the results from the United Kingdom
Version: 
1 
Date: 
07 Sep 2020
Reviewer's report:
General Comment 
The paper addresses relevant aspects of QoL in CD patients, in a comprehensive
population . Reported results are interesting as well as the comparison with a
similar British study which reveals important differences between both
populations. 
However there are some major issues to consider: 
How reliable is it to answer a survey related to an event years after the event has
occurred? In adult participants many years elapsed between diagnosis and the
survey concerning the Diagnosis period and the years before. Specifically how
reliable are data concerning consultations before the diagnosis . etc 
Similarly the lower change in EQ-Index in Polish coeliac respondents as
compare to UK could be related 
to QoL information given by parents and
children being less accurate as compared to the personal feeling refered by the
adult patient. In the British study as the cipher of <18y at dx was 
12% its impact
on the whole population 
is probably very low. In the polish serie , <18 y
represents 
exactly the same number as the 18-34 y subgroup , i.e . 282 ( 36.7%) 
These limitation needs to be addressed in the Discussion.
The pediatric population representing 36% of the study population the results of
this subgroup should be analysed separately and compared with data from adults
. This would give more reliable 
information on the characteristics of CD
diagnosis in Poland 
and give some clues on how to improve awareness and
earlier diagnosis. 
At least it is worthy to analyze this subgroup separately 
r parameters like ; 
Symptoms
Duration of symptoms before Dx 
Compliance with the GFD
Also comparing 
Diagnosed 
before and after the year 2000 
It would be also interesting to compare 
Diagnostic process in children versus
adults . This could support the view outed in the Discussion of 
CD being still
considered a pediatric disease in Poland in the late 90´s . 
Some specific comments 
Page 2 L 52 Many researchers have suggested that extra-intestinal symptoms are
increasingly frequently the only manifestation of CD, especially in older children
and adults. 
The writing leads to confusion . Please modify it 
Page 2 L 54 It has not been established whether this results from an increasing
incidence of non-classical CD, greater awareness in physicians and CD patients
(6), or more effective detection of CD in adults in recent years.
I suggest to modify the writing into: 
It has not been established whether this results from a true 
increasing incidence
of non-classical CD, or from 
greater awareness of physicians and CD patients
(6), or from 
more effective detection of CD in adults in recent years.
Page 3 L 3 : 
Reference is missing 
Page 3 L9 That finding, and suspicion that in Poland the mean time between the
onset of coeliac symptoms and CD diagnosis can be even longer than in the UK,
encouraged the authors of this study to conduct a similar study using comparable
instruments and methods among Polish CD patients.
I suggest to modify the writing into: 
That finding, and suspicion that in Poland the mean time between the onset of
coeliac symptoms and CD diagnosis could 
be even longer than in the UK 
lead us
to 
conduct a similar study using comparable instruments and methods among
Polish CD patients.
Page 3 L 7 Suspicion that in Poland the mean time between the onset of coeliac
symptoms and CD diagnosis can be even longer than in the UK, encouraged the
authors of this study to conduct a similar study using comparable instruments
and methods among Polish CD patients.
What was the rationale for this suspicion ?
Also it looks like the main aim is to compare the data from Poland to those of
the British study 
either than to learn about the specific situation in Poland . 
Page 4 L 22 respondents were asked to assess their quality of life at the time of
their diagnosis and at the time of the survey.
How reliable is to answer a survey related to the time of diagnosis 
years after the
diagnosis has been made . 
Are responses to Questions like Q8 
reliable ??
8. During the time that you had symptoms related to coeliac disease but had not
yet been diagnosed, approximately how many days did you take off work due to
your symptoms? 
Page 8 L17 : Polish answerers before CD diagnosis had more problems with
anxiety and depression (p<0.001) and self-care (p<0.002). 
I suggest to modify the writing into: 
Polish answerers 
had before CD diagnosis 
more problems with anxiety and
depression (p<0.001) and self-care (p<0.002).
Page 11 L 23-32 
Those results met with some disbelief among Polish clinicians, which
encouraged the authors of this study to conduct a similar analysis in Poland,
using a similar questionnaire and methods. 
A similar number of surveyees took part in the Polish and in the British study.
CD affects females more often than males and this was confirmed in both
studies, with a majority of females in each study group.
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons upon publication of the manuscript. If you have already registered at
Publons, they will notify you of the receipt of this review and update your profile
as per your settings and their policy. If you are not registered with Publons, you
will receive an email from them asking you to register in order for them to be
able to recognize your review on your new profile page. Publons may use the
Review Data to generate derivative metadata for the benefit of Publons and you
as a reviewer, carefully considering the sensitivity of such information. For
example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help
editors to identify candidate reviewers. Please find the details of processing in
Publons’ privacy policy 
https://publons.com/about/terms
No
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no comepting interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Please review this paper.
user
Reviewer’s report
Title: 
The impact of symptoms on quality of life before and after diagnosis of
coeliac disease: the results from a Polish population survey and comparison with
the results from the United Kingdom
Version: 
1 
Date: 
07 Sep 2020
Reviewer's report:
General Comment 
The paper addresses relevant aspects of QoL in CD patients, in a comprehensive
population . Reported results are interesting as well as the comparison with a
similar British study which reveals important differences between both
populations. 
However there are some major issues to consider: 
How reliable is it to answer a survey related to an event years after the event has
occurred? In adult participants many years elapsed between diagnosis and the
survey concerning the Diagnosis period and the years before. Specifically how
reliable are data concerning consultations before the diagnosis . etc 
Similarly the lower change in EQ-Index in Polish coeliac respondents as
compare to UK could be related 
to QoL information given by parents and
children being less accurate as compared to the personal feeling refered by the
adult patient. In the British study as the cipher of <18y at dx was 
12% its impact
on the whole population 
is probably very low. In the polish serie , <18 y
represents 
exactly the same number as the 18-34 y subgroup , i.e . 282 ( 36.7%) 
These limitation needs to be addressed in the Discussion.
The pediatric population representing 36% of the study population the results of
this subgroup should be analysed separately and compared with data from adults
. This would give more reliable 
information on the characteristics of CD
diagnosis in Poland 
and give some clues on how to improve awareness and
earlier diagnosis. 
At least it is worthy to analyze this subgroup separately 
r parameters like ; 
Symptoms
Duration of symptoms before Dx 
Compliance with the GFD
Also comparing 
Diagnosed 
before and after the year 2000 
It would be also interesting to compare 
Diagnostic process in children versus
adults . This could support the view outed in the Discussion of 
CD being still
considered a pediatric disease in Poland in the late 90´s . 
Some specific comments 
Page 2 L 52 Many researchers have suggested that extra-intestinal symptoms are
increasingly frequently the only manifestation of CD, especially in older children
and adults. 
The writing leads to confusion . Please modify it 
Page 2 L 54 It has not been established whether this results from an increasing
incidence of non-classical CD, greater awareness in physicians and CD patients
(6), or more effective detection of CD in adults in recent years.
I suggest to modify the writing into: 
It has not been established whether this results from a true 
increasing incidence
of non-classical CD, or from 
greater awareness of physicians and CD patients
(6), or from 
more effective detection of CD in adults in recent years.
Page 3 L 3 : 
Reference is missing 
Page 3 L9 That finding, and suspicion that in Poland the mean time between the
onset of coeliac symptoms and CD diagnosis can be even longer than in the UK,
encouraged the authors of this study to conduct a similar study using comparable
instruments and methods among Polish CD patients.
I suggest to modify the writing into: 
That finding, and suspicion that in Poland the mean time between the onset of
coeliac symptoms and CD diagnosis could 
be even longer than in the UK 
lead us
to 
conduct a similar study using comparable instruments and methods among
Polish CD patients.
Page 3 L 7 Suspicion that in Poland the mean time between the onset of coeliac
symptoms and CD diagnosis can be even longer than in the UK, encouraged the
authors of this study to conduct a similar study using comparable instruments
and methods among Polish CD patients.
What was the rationale for this suspicion ?
Also it looks like the main aim is to compare the data from Poland to those of
the British study 
either than to learn about the specific situation in Poland . 
Page 4 L 22 respondents were asked to assess their quality of life at the time of
their diagnosis and at the time of the survey.
How reliable is to answer a survey related to the time of diagnosis 
years after the
diagnosis has been made . 
Are responses to Questions like Q8 
reliable ??
8. During the time that you had symptoms related to coeliac disease but had not
yet been diagnosed, approximately how many days did you take off work due to
your symptoms? 
Page 8 L17 : Polish answerers before CD diagnosis had more problems with
anxiety and depression (p<0.001) and self-care (p<0.002). 
I suggest to modify the writing into: 
Polish answerers 
had before CD diagnosis 
more problems with anxiety and
depression (p<0.001) and self-care (p<0.002).
Page 11 L 23-32 
Those results met with some disbelief among Polish clinicians, which
encouraged the authors of this study to conduct a similar analysis in Poland,
using a similar questionnaire and methods. 
A similar number of surveyees took part in the Polish and in the British study.
CD affects females more often than males and this was confirmed in both
studies, with a majority of females in each study group.
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons upon publication of the manuscript. If you have already registered at
Publons, they will notify you of the receipt of this review and update your profile
as per your settings and their policy. If you are not registered with Publons, you
will receive an email from them asking you to register in order for them to be
able to recognize your review on your new profile page. Publons may use the
Review Data to generate derivative metadata for the benefit of Publons and you
as a reviewer, carefully considering the sensitivity of such information. For
example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help
editors to identify candidate reviewers. Please find the details of processing in
Publons’ privacy policy 
https://publons.com/about/terms
No
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no comepting interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
assistant