Title: Celiac disease autoimmunity among Nigerian children and adolescents with type 1
diabetes mellitus
Version: 5 Date: 31 Aug 2024
Reviewer's report:
The authors from Nigeria reported celiac seropositivity (not the actual biopsy-confirmed CD) in
6/104 diabetic children (T1DM), approximately 6% and 4/6 cases had nonspecific GI symptoms
but only one child (<1% prevalence of biopsy-confirmed CD in this cohort or almost 2% if
counted patient No. 4 in Table 2 as CD) underwent duodenal biopsy, while the other 4 out of 5
children should had undergone duodenal biopsy (patients No .2, 3, 5, 6from table 2).
I feel that the study had some important limitations.
1. For the above reason, the title of this important study should be changed to "
Celiac seropositivity in ....." not celiac disease itself as most seropositive cases did not undergo
duodenal biopsy.  Information on the limitations with regards to duodenal biopsy to confirm CD
should be initially mentioned in the Abstract for transparency.
2. Nausea, vomiting, diarrhea, bloating are all nonspecific GI symptoms that can occur in IBS,
FGID, lactose intolerance, bacterial overgrowth, or even diabetic neuropathy of the GI tract
itself, etc. All these conditions may even be more common in Nigeria (and many other countries
in the world). Please comment on this point. Were there any screening questions or test such as
hydrogen breath test to rule out  the aforementioned condition.
A  previous study  (https://pubmed.ncbi.nlm.nih.gov/26508189/) also reported that diabetic
children with celiac seropositivity actually had less prevalent GI symptoms.  It may be
worthwhile to discuss this issue  with the similar/different previous studies.
3. Please explain the biological plausibility of gender predilection in CD-associated T1DM (not
just the CD itself), or if this just occurred by chance.
Minor points
- What is the definition of 'rather low TTG' or moderate elevation? Please define in the Methods.
- No need add Figure 1 to the study as it does not add much value to the reported data esp. with
Marsh I ?  Even more confused as the manuscript text and Table 2 (patient 1) explained the
histopathology of Marsh III due to the blunted villi but the Figure 1 exhibits Marsh I - please
clarify (or just consider dropping the Figure out).
Title: Celiac disease autoimmunity among Nigerian children and adolescents with type 1
diabetes mellitus
Version: 5 Date: 31 Aug 2024
Reviewer's report:
The authors from Nigeria reported celiac seropositivity (not the actual biopsy-confirmed CD) in
6/104 diabetic children (T1DM), approximately 6% and 4/6 cases had nonspecific GI symptoms
but only one child (<1% prevalence of biopsy-confirmed CD in this cohort or almost 2% if
counted patient No. 4 in Table 2 as CD) underwent duodenal biopsy, while the other 4 out of 5
children should had undergone duodenal biopsy (patients No .2, 3, 5, 6from table 2).
I feel that the study had some important limitations.
1. For the above reason, the title of this important study should be changed to "
Celiac seropositivity in ....." not celiac disease itself as most seropositive cases did not undergo
duodenal biopsy.  Information on the limitations with regards to duodenal biopsy to confirm CD
should be initially mentioned in the Abstract for transparency.
2. Nausea, vomiting, diarrhea, bloating are all nonspecific GI symptoms that can occur in IBS,
FGID, lactose intolerance, bacterial overgrowth, or even diabetic neuropathy of the GI tract
itself, etc. All these conditions may even be more common in Nigeria (and many other countries
in the world). Please comment on this point. Were there any screening questions or test such as
hydrogen breath test to rule out  the aforementioned condition.
A  previous study  (https://pubmed.ncbi.nlm.nih.gov/26508189/) also reported that diabetic
children with celiac seropositivity actually had less prevalent GI symptoms.  It may be
worthwhile to discuss this issue  with the similar/different previous studies.
3. Please explain the biological plausibility of gender predilection in CD-associated T1DM (not
just the CD itself), or if this just occurred by chance.
Minor points
- What is the definition of 'rather low TTG' or moderate elevation? Please define in the Methods.
- No need add Figure 1 to the study as it does not add much value to the reported data esp. with
Marsh I ?  Even more confused as the manuscript text and Table 2 (patient 1) explained the
histopathology of Marsh III due to the blunted villi but the Figure 1 exhibits Marsh I - please
clarify (or just consider dropping the Figure out).
Please review this paper.
user
Title: Celiac disease autoimmunity among Nigerian children and adolescents with type 1
diabetes mellitus
Version: 5 Date: 31 Aug 2024
Reviewer's report:
The authors from Nigeria reported celiac seropositivity (not the actual biopsy-confirmed CD) in
6/104 diabetic children (T1DM), approximately 6% and 4/6 cases had nonspecific GI symptoms
but only one child (<1% prevalence of biopsy-confirmed CD in this cohort or almost 2% if
counted patient No. 4 in Table 2 as CD) underwent duodenal biopsy, while the other 4 out of 5
children should had undergone duodenal biopsy (patients No .2, 3, 5, 6from table 2).
I feel that the study had some important limitations.
1. For the above reason, the title of this important study should be changed to "
Celiac seropositivity in ....." not celiac disease itself as most seropositive cases did not undergo
duodenal biopsy.  Information on the limitations with regards to duodenal biopsy to confirm CD
should be initially mentioned in the Abstract for transparency.
2. Nausea, vomiting, diarrhea, bloating are all nonspecific GI symptoms that can occur in IBS,
FGID, lactose intolerance, bacterial overgrowth, or even diabetic neuropathy of the GI tract
itself, etc. All these conditions may even be more common in Nigeria (and many other countries
in the world). Please comment on this point. Were there any screening questions or test such as
hydrogen breath test to rule out  the aforementioned condition.
A  previous study  (https://pubmed.ncbi.nlm.nih.gov/26508189/) also reported that diabetic
children with celiac seropositivity actually had less prevalent GI symptoms.  It may be
worthwhile to discuss this issue  with the similar/different previous studies.
3. Please explain the biological plausibility of gender predilection in CD-associated T1DM (not
just the CD itself), or if this just occurred by chance.
Minor points
- What is the definition of 'rather low TTG' or moderate elevation? Please define in the Methods.
- No need add Figure 1 to the study as it does not add much value to the reported data esp. with
Marsh I ?  Even more confused as the manuscript text and Table 2 (patient 1) explained the
histopathology of Marsh III due to the blunted villi but the Figure 1 exhibits Marsh I - please
clarify (or just consider dropping the Figure out).
assistant