Maternal Dietary Patterns, Food Security and Multivitamin Use as Determinants of Non-Syndromic Orofacial Clefts Risk in Ghana: A Case–Control Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript represents relevant evidence understanding maternal risk for OFCs, specifically about nutrition. However, it needs some changes in order to improve it:

1) Within the Abstract, the tem "T3" is not clear. Readers may assume that it refers to Tertile 3 or not. In addition in this section, there is no clarity if the low intake of folic acid was detected in mother of cases, mothers of controls or both. 

2) The OFC cases are all nonsyndromic. Therefore, this concept must be included in the manuscript title and in the whole text. 

3) The authors state that continuous variables were analyzed by T-test but there is no previous test for normality of the distribution.

4) For food security levels (Table 2), the global Pearson p-values is not significant. However, certain levels has different proportion among cases and controls. Thus, authors must include other statistical test to evaluate this specific differences.

5) In Table 6, despite animal-vegetable protein T3 shows a significant p-value, its confidence intervals includes the value 1. This fact must be discussed in the context of a borderline significance. 

6) Within Discussion section, the low folic acid intake in both group would be enriched with prevalence data of OFCs and/or NTDs in Ghana in comparison with others countries or regions, in order to find a relation between both factors. 

 

Author Response

Comment 1: Within the Abstract, the term "T3" is not clear. Readers may assume that it refers to Tertile 3 or not. In addition, in this section, there is no clarity if the low intake of folic acid was detected in mother of cases, mothers of controls or both. 

Response 1: We thank the reviewer for this insightful comment, and we agree with the reviewer. We have addressed the concerns as follows: We have defined T1, T2 and T3 at the first mention in both the Abstract and results section to specify that they represent tertiles of dietary pattern intake: T1=Lower intake, T2 moderate intake, T3=highest intake. This can be seen in Page 1 Line 22, Page 6, line 149 and 150. We have also revised the abstract to indicate that folic acid was low in both groups. Page 1, line 27.

2) The OFC cases are all nonsyndromic. Therefore, this concept must be included in the manuscript title and in the whole text. 

Response 2: Thank you for this important observation. We have revised the manuscript title and clarified throughout the text that the study focuses on non-syndromic orofacial clefts (NSOFCs) We have also updated the introduction sections to define NSOFCs. The changes can be seen in Page 1, Line 2, 12, 15, 30. Line 41-45, 48,59,73,80, 145, 146, 151, 156, 161, 171, 180, 197, 203, 222, 223, 229, 232, 244, 248, 252, 262, 268, 269, 278, 282, 294, 308, 309, 343, 345, 346, 354

3) The authors state that continuous variables were analyzed by T-test but there is no previous test for normality of the distribution.

Response 3: Thank you for this helpful observation. In our original Methods section, we included a reference to the use of independent t-tests. However, all variables analyzed in this study were categorical (e.g., education, occupation, food security status, dietary patterns, supplement use), and no continuous variables were included in the final analysis. Therefore, t-tests were not applied. We have corrected the Methods section to read: “Differences between case and control groups were assessed using Pearson’s chi-square tests for categorical variables.” This change ensures consistency between the methods and the reported results. The changes can be seen in Page 10, line 331.

4) For food security levels (Table 2), the global Pearson p-values is not significant. However, certain levels has different proportion among cases and controls. Thus, authors must include other statistical test to evaluate this specific differences.

Response 4: We appreciate the reviewer’s comment. Following your suggestion, we performed post-hoc pairwise comparison using Fisher’s exact test with Bonferroni correction to assess differences between specific food security categories among cases and control. Although mildly food-insecure mothers were less frequent among cases (5.8%), this difference was not statistically significant after the correction (p=0.122). No categories showed significant differences. We have updated the results and discussion sections accordingly. Updates can be seen in Table 2 (line 95, 99) and line 169,170 and 172

5) In Table 6, despite animal-vegetable protein T3 shows a significant p-value, its confidence intervals includes the value 1. This fact must be discussed in the context of a borderline significance. 

Response 5: We thank reviewer for this important observation. We have revised the discussion section to clarify this point. Page 8, Line 238,239

6) Within Discussion section, the low folic acid intake in both groups would be enriched with prevalence data of OFCs and/or NTDs in Ghana in comparison with other countries or regions, to find a relation between both factors. 

Response 6: Thank you for this insightful suggestion. We have revised the Discussion section to include a comparison of our findings on low folic acid intake and available data on the prevalence of OFC and NTDs in Ghana and other countries that have implemented effective folic acid supplementation and fortification programs. Page 7, line 183-188

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript "Maternal Dietary Patterns, Food Security and Multivitamin Use as Determinants of Orofacial Clefts Risk in Ghana: A Case-Control Study" addresses an important and underexplored public health problem: the role of maternal dietary patterns, supplement use, and food security in the risk of orofacial clefts (OFCs) in a low-resource setting. The study is original, relevant, and well-aligned with global health priorities, particularly in sub-Saharan Africa where data on nutritional risk factors for congenital anomalies are scarce. The topic is highly significant for both researchers and policymakers.

Overall, the manuscript is coherent, well-structured, and scientifically sound. The research question is clear, the methodology is appropriate, and the results are relevant and provide new insights. The English is generally understandable and of good quality, though some sentences could be tightened for conciseness and clarity.

1. Methodology

The study design is suitable for addressing the research question. Case-control studies are appropriate for rare outcomes like OFCs.

Sampling: Case and control mothers were well-matched by child’s sex and delivery month, which strengthens internal validity.

Dietary Assessment: Use of a food frequency questionnaire and PCA to identify dietary patterns is standard and acceptable. However, reliance on self-reported dietary recall introduces potential recall bias, which is acknowledged in the discussion.

Statistical Analysis: Logistic regression models adjusting for key confounders (food security, multivitamin, folic acid use) were correctly applied. Reporting of odds ratios and confidence intervals is clear.

2. Results

Results are presented clearly with appropriate tables.

The finding that "Sweet and Energy-Dense" and "Staple Plant-Based" diets increase OFC risk, while "Animal Protein-Vegetable" is protective, is both logical and well-supported.

Low multivitamin and folic acid use (<15%) is an important and actionable finding.

Some reported p-values (e.g., borderline significance) could be better contextualized, avoiding over-interpretation.

3. Discussion

The discussion effectively integrates results with existing literature, situating the findings within broader evidence on nutrition and congenital anomalies.

The potential mechanisms linking sugar-rich and starchy diets with oxidative stress and micronutrient deficiencies are well explained.

Limitations (recall bias, retrospective dietary reporting, sample size constraints) are acknowledged, which strengthens transparency.

Applicability to policy and maternal health programs in Ghana and similar LMIC contexts is highlighted, giving the study strong practical relevance.

4. Conclusions

The conclusions are consistent with the results and discussion.

The recommendation for improving maternal diet quality, supplement uptake, and addressing food insecurity is appropriate and evidence-based.

Quality of English

The English is overall clear and professional, though some sections are slightly wordy or repetitive.

Minor editing for conciseness, grammar, and flow could improve readability. For example:

“These variations, though not statistically significant suggest…” → “Although not statistically significant, these variations suggest…”

“This strong association suggests that high sugar and processed food intake during the periconceptional period may be an important nutritional risk factor that negatively affects pregnancy outcomes…” → This could be shortened for clarity.

Final Recommendation

The manuscript is of high scientific quality and provides novel, relevant findings. I recommend acceptance after minor revisions focusing on:

Improving conciseness and clarity of the English.

Avoiding over-interpretation of borderline p-values.

Strengthening the policy/practical implications in the conclusion (e.g., linking findings more directly to maternal health programs or supplementation policies in Ghana).

Comments on the Quality of English Language

Quality of English

The English is overall clear and professional, though some sections are slightly wordy or repetitive.

Minor editing for conciseness, grammar, and flow could improve readability. For example:

“These variations, though not statistically significant suggest…” → “Although not statistically significant, these variations suggest…”

“This strong association suggests that high sugar and processed food intake during the periconceptional period may be an important nutritional risk factor that negatively affects pregnancy outcomes…” → This could be shortened for clarity.

Author Response

Comment 1: Some reported p-values (e.g., borderline significance) could be better contextualized, avoiding over-interpretation.

Response 1: Thank you for your observation. We agree that some of the reported p-values and 95% Confidence interval suggests a borderline association. The discussion has been interpreted accordingly. Page 8 line 238 to 239.

Comment 2: Improving conciseness and clarity of the English.

Response 2: We thank reviewer for this observation. We have reviewed the manuscript for language precision. Changes have been made to lines: 15, 19, 24-25, 26, 54, 64, 84, 117, 120, 125, 138, 140, 141, 227, 229, 313, 324, 330, and 341.   

Comment 3: Avoiding over-interpretation of borderline p-values.

Response 3: Thank you for your observation. We agree that some of the reported p-values and 95% Confidence intervals suggest a borderline association. The discussion has been interpreted accordingly. Page 8 line 238 to 239

Comment 4: Strengthening the policy/practical implications in the conclusion (e.g., linking findings more directly to maternal health programs or supplementation policies in Ghana).

Response 4: Thank you for the suggestion. We have revised the conclusion to emphasize public health relevance of our findings. Page 10 line 350-354

Reviewer 3 Report

Comments and Suggestions for Authors

Review of the Article: Review of the Article: "Maternal Dietary Patterns, Food Security and Multivitamin Use as Determinants of Orofacial Clefts Risk in Ghana: A Case-Control Study"

 

This study investigates the association between maternal dietary patterns, food security, and multivitamin use with the risk of orofacial clefts (OFCs) in Ghana. The authors conducted a matched case-control study with 103 mothers of children with OFCs and 103 control mothers. Dietary patterns were identified through principal component analysis, and food security was assessed using the USDA 18-item scale. The study found that adherence to Sweet and Energy-Dense and Staple Plant-Based dietary patterns was associated with increased OFC risk, while the Animal Protein-Vegetable pattern suggested a protective effect. Severe food insecurity was more common among case-mothers, and periconceptional multivitamin and folic acid use was low.

General Concept Comments:

The study addresses an important public health issue in a resource-limited setting. However, there are some methodological limitations and areas for improvement:

Sample Size: The study included a relatively small number of participants, which may limit the statistical power and generalizability of the findings.

Matching Criteria: The matching criteria (maternal age) are appropriate, but additional variables, such as socioeconomic status, could have been considered to improve the comparability of the groups.

Dietary Assessment: The use of a food frequency questionnaire is a common method, but it may not capture the full complexity of dietary intake. A more detailed dietary assessment tool, such as a 24-hour recall, could provide more accurate data.

Food Security: The USDA 18-item scale is a validated tool, but it may not fully capture the nuances of food insecurity in a Ghanaian context.

Specific Comments:

The article is in a broken order - introduction, materials and methods, results, conclusion. After reading the results, it is illogical to get acquainted with the materials and methods.

The authors should clearly spell out the inclusion and exclusion criteria. It is not clear about other pathologies, including those on the part of women

Provide characteristics of women - obstetric and gynecological history, burdened heredity, bad habits, somatic diseases.

When indicating the use of multivitamin complexes and folic acid, I consider it important to emphasize the dose of folic acid in their composition.

The conclusion should be expanded, with clearer limitations of the study, some discussion of cause and effect, perhaps a potential role for homocysteine.

General Questions:

Is the manuscript clear, relevant for the field and presented in a well-structured manner? The manuscript is generally clear and well-structured.

Are the cited references mostly recent publications (within the last 5 years) and relevant? The references appear to be relevant, but a more detailed analysis of their publication dates would enhance the scientific basis of the review.

Is the manuscript scientifically sound and is the experimental design appropriate to test the hypothesis? The study design is appropriate for a case-control study, but the small sample size limits the generalizability of the findings.

Are the manuscript’s results reproducible based on the details given in the methods section? The methods section provides a general overview of the study design, but more detailed information on the dietary assessment and maternal characteristics.

Are the figures/tables/images/schemes appropriate? Do they properly show the data? Are they easy to interpret and understand? Yes

As a visual person, I was missing the main image of the article. But that's at the discretion of the editors.

Are the conclusions consistent with the evidence and arguments presented? The conclusions are generally consistent with the data presented, but the authors should acknowledge the limitations of the study and the need for further research.

Please evaluate the ethics statements and data availability statements to ensure they are adequate. The manuscript contains ethical statements or data availability statements.

 

Overall Assessment:

This study provides valuable insights into the role of maternal diet and food security in the risk of OFCs in Ghana. While the findings are promising, the study is limited by its small sample size and the lack of detailed dietary assessment. Further research with larger sample sizes and more comprehensive dietary assessment tools is needed to confirm these findings and develop effective public health interventions.

Author Response

General Concept Comments:

The study addresses an important public health issue in a resource-limited setting. However, there are some methodological limitations and areas for improvement:

Comment 1: Sample Size: The study included a relatively small number of participants, which may limit the statistical power and generalizability of the findings.

Response 1: We appreciate the reviewer’s observation. We acknowledge that the relatively small sample size may limit the statistical power to detect subtle association and affect generalizability of our findings. This has been included in the limitations in the discussion section. Page 8, line 255-261

Comment 2: Matching Criteria: The matching criteria (maternal age) are appropriate, but additional variables, such as socioeconomic status, could have been considered to improve the comparability of the groups.

Response 2: Thank you for this observation. We would like to clarify that mothers were not matched by age. Instead, cases and controls were matched by age and sex. Also, during the matching, we ensured the demographic comparability of the case and the control mothers.

Comment 3: Dietary Assessment: The use of a food frequency questionnaire is a common method, but it may not capture the full complexity of dietary intake. A more detailed dietary assessment tool, such as a 24-hour recall, could provide more accurate data.

Response 3: Thank you for your comment. We agree that 24-hour recalls can provide detailed dietary information; however, for this study, we aimed to assess habitual dietary patterns over the periconceptional period, making FFQ the most suitable tool. Further, the FFQ we used has been widely used in Ghana for similar studies and have been shown to be appropriate for evaluating usual intake patterns.

Comment 4: Food Security: The USDA 18-item scale is a validated tool, but it may not fully capture the nuances of food insecurity in a Ghanaian context.

Response 4: Thank you for this insightful comment. We selected the USDA 18-item Household Food Security Scale because it is a widely validated and internationally recognized tool that allows comparability across studies. Additionally, we carefully adapted the wording of certain items to align with the Ghanaian context while maintaining the original structure and scoring system to preserve its validity and reliability. This approach ensured that the measure remained both culturally relevant and methodologically robust for our study population

Specific Comments:

Comment 5: The article is in a broken order - introduction, materials and methods, results, conclusion. After reading the results, it is illogical to get acquainted with the materials and methods.

Response 5: We appreciate this observation. We would like to clarify that the order of sections (Introduction → Results → Discussion → Materials and Methods → Conclusion) was prepared in strict adherence to the journal’s official author template and instructions. We recognize that this arrangement may differ from the conventional IMRaD (Introduction, Methods, Results, Discussion) format; however, we followed the prescribed structure to ensure compliance with the journal’s style guide. Should the editorial office prefer a reordering into the conventional format, we are happy to revise accordingly.

Comment 6: The authors should clearly spell out the inclusion and exclusion criteria. It is not clear about other pathologies, including those on the part of women

Response 6: Thank you for your comment. We have clarified the inclusion criteria in the methods section. Participant selection was based on child characteristics with no exclusion for mothers. All mothers who consented and provided complete dietary and food security data were included in the study. Page 9 Line 286-289

Comment 7: Provide characteristics of women - obstetric and gynecological history, burdened heredity, bad habits, somatic diseases.

Response 6: We thank the reviewer for this comment. In this study we did not collect detailed information on obstetric or gynecological history, hereditary conditions etc for the women.  The focus of the study was on maternal dietary patterns, food security, and periconceptional supplement use

Comment 7: When indicating the use of multivitamin complexes and folic acid, I consider it important to emphasize the dose of folic acid in their composition.

Response 7: We appreciate this insightful comment. In our study, mothers who reported using standalone folic acid supplements indicated the standard dosage of 400 µg per tablet, and we have clarified this in the Methods. Page 10 Line 323 -324.

Comment 8: The conclusion should be expanded, with clearer limitations of the study, some discussion of cause and effect, perhaps a potential role for homocysteine.

Response 8: Thank you for this comment. The conclusion has been explained to include policy and public health implications. Page 10, line 352-356. Some other limitations have been included in improving clarity on the manuscript. Page 8 Line 255 to 261. We appreciate the reviewer’s insightful comment regarding homocysteine and its possible role in NSOFC development through one-carbon metabolism. However, our study did not measure homocysteine levels and we believe including a detailed discussion would be speculative and beyond the scope of our objectives.

 

General Questions:

Comment 11: Are the cited references mostly recent publications (within the last 5 years) and relevant? The references appear to be relevant, but a more detailed analysis of their publication dates would enhance the scientific basis of the review.

Response 11: We appreciate the reviewer’s emphasis on ensuring that our work is well-supported by recent literature. We carefully reviewed our reference list and confirmed that most of the citations are from the last five years (2020–2025). In addition, we incorporated several recent studies and reviews on maternal diet, folic acid supplementation, and orofacial clefts to further strengthen the scientific basis of the manuscript.

Comment 12: As a visual person, I was missing the main image of the article. But that's at the discretion of the editors.

Response 12: We thank the reviewer for this suggestion. A graphical abstract was already included in our submission package to visually summarize the study design and key findings. We are, of course, open to including an additional figure within the main text if the editors believe it would improve clarity for readers.

Comment 13: Are the conclusions consistent with the evidence and arguments presented? The conclusions are generally consistent with the data presented, but the authors should acknowledge the limitations of the study and the need for further research.

Response 13: Authors have fully acknowledged the limitation of the work in the limitation section as well as the need for further studies.