Lifestyle Medicine Perspectives from Nursing in Community Care Setting: A Narrative Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors.

The review addresses the integration of community nursing (IFeC) with Lifestyle Medicine (LM) in the care of chronic diseases, an area of growing interest in clinical practice and health management. It combines experimental, observational and qualitative studies, offering a comprehensive overview of community interventions and their impact on self-care, empowerment and clinical outcomes.

Overall, the topic is relevant. I offer some suggestions with the aim of improving your manuscript.

In the abstract, the lifestyle medicine offer should be Lifestyle offers.

The introduction presents a solid epidemiological contextualisation with an updated theoretical framework.  Coherently, it is articulating the global burden of chronic diseases with the development of the Chronic Care Model and the evolution of the nursing role. Furthermore, it adequately integrates the LM framework and justifies the strategic relevance of IFeC in the Italian and European context.

In the objectives, ‘Possible role’ sounds weak or speculative and can be interpreted as a lack of scientific positioning. We suggest changing it to ‘the role’ or ‘the contribution,’ maintaining exactly the same meaning but with greater academic solidity.

The narrative review methodology is robust and well aligned with the study objectives. The clear structure of objectives, research questions, PICOS framework, inclusion/exclusion criteria, double-reviewer screening, and quality assessment using SANRA and CASP lend rigour, transparency, and credibility to the narrative synthesis.

However, some clarifications, greater explicitness, and technical justification are suggested to strengthen methodological transparency and avoid possible confusion with a systematic review:

• Add a brief justification for choosing a narrative approach over a systematic one, explaining the heterogeneity of studies, contexts, and types of intervention.
• Specify operational criteria for defining ‘community nursing strategies in LM view’ so that the classification of interventions is more concrete and reproducible. For example, specify concrete criteria for classifying interventions within LM, such as the presence of certain lifestyle pillars or a focus on prevention and self-care.
• Detail how CASP was applied according to the type of study and how this assessment was integrated into the synthesis of results.

These modifications will increase the clarity, consistency and confidence in the review.

Also,  I have observed a possible tension between narrative design and systematic structure

The use of PICOS, formal screening and risk of bias assessment may raise doubts as to whether it is really a narrative or an incomplete systematic review.

I suggest adding a brief methodological justification explaining that a narrative review was chosen due to the heterogeneity of designs, contexts, and types of intervention, which prevented a quantitative synthesis.

Although it is a narrative review, this example uses elements typical of a formal protocol: clear objectives, defined questions, inclusion criteria, structured search, and quality assessment. This makes it more robust and reliable, with scientific rigour similar to a systematic review without losing its flexibility.

Overall, the discussion is robust and coherent, but also, there are some redundancies. It is mentioned several times that community nursing and IFeC are key to the integration of chronic care and LM. Although this is a central message, some phrases could be consolidated into a single strong statement to avoid repeating it several times. The concepts of self-management, empowerment, and healthy behaviour are mentioned many times. The findings could be grouped into a more concise paragraph that combines clinical and organisational evidence.

The conclusions are also, robust and coherent and are well aligned with the objectives.

Warm regards.

The reviewer

Author Response

Dear Peer,

Thank you very much for your effort and time. We hope that in this version, according your precious comments, the manuscript will be suitable for publication.

Thank you again,

all Authors

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

1. Title and Abstract
Strengths

The title clearly reflects the subject and scope of the review.

The abstract is well-organized and summarizes the background, methodology, findings, and conclusions.

Key concepts, such as community nursing, chronic care, and lifestyle medicine, are clearly presented.

Points for Improvement

Please emphasize the novelty of the review more clearly in the abstract.

Avoid general or vague statements in the abstract conclusion; make it more precise and aligned with the findings.

Please briefly explain why a narrative review format was chosen.

Minor language adjustments are needed to improve clarity and conciseness.

2. Introduction
Strengths

Provides a comprehensive background on chronic diseases and the challenges facing the healthcare system.

Integrates international and national policy perspectives.

Clearly presents the chronic care and lifestyle medicine model.

Appropriately defines the role of the Family and Community Nurse (IFeC).

Points for Improvement

The introduction is lengthy and could be shortened to focus the research. 

Some policy descriptions are overly detailed and could be shortened.

The research gap needs to be clarified more precisely:

What is missing from current reviews?

Why is this review necessary?

Reducing redundancy regarding the burden of chronic disease and nursing development.

Clearly separating background information from study objectives.

3. Objectives
Strengths

Main and secondary objectives are identified.

The emphasis on the integration of international and lifestyle medicine is clear.

Points for Improvement

Improving the wording for greater clarity (e.g., the phrase "international, European, and national View" could be simplified).

Please add a brief statement outlining the expected contribution to practice or policy.

4. Materials and Methods
Strengths

The narrative review design is clearly described.

SANRA criteria are mentioned.

The PICOS framework enhances methodological transparency.

The screening process and inclusion criteria are described.

Points for Improvement

More clearly justify why a narrative review was chosen over a systematic review.

Provide additional details about the search strategy:

Include the full search terms (if not fully detailed in the appendix).

Indicate whether MeSH terminology was used.

Specify if only PubMed was used, and justify this choice.

Explain how reviewer disagreements were resolved (consensus process? Third-party review?).

Explain how CASP quality assessments influenced study inclusion or grouping.

Explain why all studies received a "positive" rating in the quality assessment.

5. Results
Strengths

The flowchart clearly illustrates the study selection process.

Tables summarizing study characteristics are helpful.

Clearly categorize studies into:

Patient-level interventions

Health system-level interventions

Contextual barriers

Points for improvement

Ensure the results section focuses on description and analysis rather than interpretation.

Avoid using evaluative language (such as "proved" or "demonstrated") unless supported by strong evidence.

Explain the consistency of findings across studies.

Define the strength or level of evidence whenever possible.

Ensure consistency of terminology in tables and text (e.g., study design labels).

Check the consistency of table formatting.

6. Discussion
Strengths

Strong integration with health policies and their implications at the health system level.

Linking findings to broader governance and regulatory frameworks.

Highlighting aspects of leadership and sustainability.

Points for Improvement

Begin with a concise summary of the main findings before interpretation.

Avoid repeating background information already mentioned in the introduction.

Clearly distinguish between:

Evidence-based findings,

Authors' interpretations,

Policy implications.

Modify causal claims when evidence is inconsistent.

Offer a more balanced discussion of the limitations of the reviewed studies.

Consider including comparisons with conflicting or weaker evidence where appropriate.

7. Prospects for Future Research
Strengths

Identifies the need for longitudinal and multicenter studies.

Highlights cost-effectiveness and organizational dimensions.

Points for Improvement

Provide more specific recommendations (e.g., specific outcome measures, methodological approaches).

Explain how future research can address the gaps identified in this review.

8. Strengths and Limitations
Strengths

Acknowledges the limitations of narrative design.

Refers to heterogeneity and the lack of meta-analysis.

Points for Improvement

Please state the following explicitly:

Limitations of a single database,

Potential for publication bias,

Language limitations,

Subjectivity of narrative analysis.

Explain the impact of short follow-up periods in the included studies.

 

Author Response

Dear Peer,

Thank you very much for your effort and time. We hope that in this version, according your precious comments, the manuscript will be suitable for publication.

Thank you again,

all Authors

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Please see the comments below:

Line 202: provide a table showing the results of the quality assessment for each of the included studies.

Line 258: state the parts of the world that are not represented and the implication for the generalizability and interpretation of the findings.

Line 436: state clearly that there were no studies from Africa, South America, Carribean, and Australia.

Author Response

Dear Peer,

Thank you very much for your effort and time. We hope that in this version, according your precious comments, the manuscript will be suitable for publication.

Thank you again,

all Authors

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

I commend the authors for their review of the role of community nursing, particularly Family and Community Nurses (IFeC), in chronic care management and Lifestyle Medicine (LM). This manuscript addresses a significant area of study by emphasizing the contributions of LM and IFeC nurses, and it is generally well written. However, substantial revisions are required in the analysis, results, and discussion sections.

Introduction

1. The introduction of LM occurs only on line 121 of page 3. It is recommended that chronic diseases and LM be discussed together earlier in the introduction to clearly establish their connection from the outset.
2. The discussion of chronic diseases in the introduction contains excessive detail and should be condensed to enhance clarity and focus. Repeating similar concepts across sentences can cause confusion. For instance, line 77 states “the need for a proactive, multidisciplinary, and patient-centered healthcare system…,” and again in line 94 “…strengthen multidisciplinary and community-based care.”
3. Similarly, the discussion of nurses' evolving roles should be presented more concisely. Instead, information on IFeCs and their roles outside Europe is limited and should be expanded to provide a more comprehensive perspective.
4. The introduction does not reference other studies in the field. It is important to situate this work in relation to previous research on community nurses and LM in the context of chronic diseases by citing relevant studies that have examined these interactions.

Aim:

1. The research question does not address “the role of IFeCs,” which is identified as the first aim of the study.

Methods

1. Indicate the date during when the literature search was conducted.
2. The abstract indicates that “grey literature sources, including institutional and policy reports,” were included. However, the methodology section does not address the inclusion of these sources.
3. You state that certain articles were not pertinent. Please elaborate on how you determined pertinence.
4. Line 380 refers to a “recurrent theme.” If a thematic analysis was conducted, please describe the analytical approach in the methods section.

Results

The results section requires revision to more explicitly address the research questions and to delineate the specific responsibilities of community nurses. This is also reflected in the discussion section.

1. For example, line 291 states: “Taken together, this evidence suggests that personalized education, support from family or community resources...” However, it is unclear how this evidence specifically addresses the research question concerning the role of nurses or nursing interventions.
2. Similarly, the relationship between system-level and organizational interventions and the stated research questions should be clarified.
3. In line 320, the phrase "...insufficient training in behaviour..." does not identify the specific group to whom this lack of training pertains.
4. Line 327 states, “Taken together, these findings illustrate the interdependence of patient-level strategies, organizational structure, and contextual determinants on shaping chronic care outcomes within community settings.” However, it is not evident how this statement relates to the research question.

Discussion
The discussion section includes interpretations that lack direct support from the study's results. Strengthening alignment with the findings and scientific analysis would enhance coherence. The following examples illustrate these concerns:

1. The interpretation in line 337, 'the review suggests that nurse-led interventions ...,' extends beyond the evidence provided by the study's results.
2. In line 347, the reference to 'relational proximity and continuity of care' requires clarification regarding how these conclusions are derived from the presented results.
3. The points raised in line 371 regarding fragmentation of services, limited time allocation for therapeutic education, and insufficient training extend the discussion beyond the primary focus of the study.
4. The statement 'This highlights the importance of designing care models that extend beyond the individual patient to encompass social and environmental contexts' addresses a scope broader than the study's main topic.

Author Response

Dear Peer,

Thank you very much for your effort and time. We hope that in this version, according your precious comments, the manuscript will be suitable for publication.

Thank you again,

all Authors

Author Response File: Author Response.pdf