Recursive Interplay of Family and Biological Dynamics: Adults with Type 1 Diabetes Mellitus Under the Spotlight

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I thank the authors of the manuscript "Recursive interplay of family and biological dynamics: Adults with type 1 diabetes mellitus under the spotlight" for the time they have devoted to conducting their research project and for the time they have devoted to writing their manuscript.

The manuscript is very interesting and well-written. The manuscript deals with a topical issue of interest to the scientific community.

The introduction section is intended to introduce the topic of the study. The materials and methods section describes the methodology used to conduct the study. The results section gives clear and easy to read data obtained from authors, both as a descriptive part in the text and as data reported in tables (for tables read a note). The discussion sections contain a description of data in literature compared with results obtained by authors. The conclusions are relevant to the results obtained.

Even in the editorial form, the manuscript contains very few errors.

I ask the authors to correct the spacing after the point (lines: 38).

I ask the authors to correct the written sentence in the text, because it seems that a piece of phrase is missing (Line: 95 [Ethics Commitee of = specify]).

I ask the authors to correct all the bibliographical references in the text (Line 45: "[9; 10; 11; 12]" = [9-12]. Lines: 49, 50, 52, 55, 59, 69, ...).

I ask the authors to correct the spacing after the number (line: 119-121 = 0.5mm/mmol = 0.5 mm/mmol ....).

I ask the authors to review graphically/aesthetically all the tables of the manuscript, at present they are heavy to read, not easy to read and, ugly to see. Specifically, table 2 to be redone from scratch, as well as for how it is not easy to read.

Table 2, Table 4: 1^st, 2^ndQ, 3^rdQ.

Figure 2: The authors are asked to correct the figure, in the writing of cluster 2.

I ask the authors to correct the spacing between words in lines 115, 127, 128, 249, 253.

Line 286 = [8; 39; 76]

Line 311: management".

I ask the authors to standardize in the text how they report information. For example bibliographic references are sometimes given with "; and space", sometimes with "without space" and sometimes with "with space".

Author Response

Response to Reviewer 1 Comments

All asked corrections (spacing after the point, spacing after the number, space between words, complete sentence, bibliographical references x-y) were done. Figure and table were aesthetically improved. Thank you for your detailed observations.

I ask the authors to correct the spacing after the point (lines: 38).

I ask the authors to correct the written sentence in the text, because it seems that a piece of phrase is missing (Line: 95 [Ethics Commitee of = specify]).

I ask the authors to correct all the bibliographical references in the text (Line 45: "[9; 10; 11; 12]" = [9-12]. Lines: 49, 50, 52, 55, 59, 69, ...).

I ask the authors to correct the spacing after the number (line: 119-121 = 0.5mm/mmol = 0.5 mm/mmol ....).

I ask the authors to review graphically/aesthetically all the tables of the manuscript, at present they are heavy to read, not easy to read and, ugly to see. Specifically, table 2 to be redone from scratch, as well as for how it is not easy to read.

Table 2, Table 4: 1^st, 2^ndQ, 3^rdQ.

Figure 2: The authors are asked to correct the figure, in the writing of cluster 2.

I ask the authors to correct the spacing between words in lines 115, 127, 128, 249, 253.

Line 286 = [8; 39; 76]

Line 311: management".

I ask the authors to standardize in the text how they report information. For example bibliographic references are sometimes given with "; and space", sometimes with "without space" and sometimes with "with space".

Reviewer 2 Report

Comments and Suggestions for Authors

The article is innovative and of great interest. The structure is adequate and it is easy to read. The documentation presented in the introduction is sufficient and current. However, I believe it would be appropriate to mention Wolfram syndrome as one of the rare diseases most closely related to diabetes. The primary rationale for this is that, in this syndrome, diabetes serves as the catalyst for the subsequent complications experienced by those affected.

The methodology is appropriate, the analysis is clear and well presented. However, the image appears cropped or the number 2 is misplaced. Whatever the circumstances, this issue must be rectified. Furthermore, the information that appears when the cursor is placed on the published image requires modification. In other words, when courses are placed in the image itself, it is reported that they have been obtained using AI. This would need to be adjusted and noted in the appropriate place.

The discussion would be improved by including a comparison of the results with other articles from different regions. Spain, France, etc. In the current era, there is a wealth of scientific information at our disposal that can assist us in accurately contrasting our work. This would undoubtedly improve the quality of the work.

Having modified the previous point, it would be necessary to expand on the conclusions.

Finally, as I suggested earlier, it is necessary to point out that an artificial intelligence has been used to generate the image provided in the article.

Author Response

Response to Reviewer 2 Comments

Thank you for your helpful and insighful comments. 

Introduction	it would be appropriate to mention Wolfram syndrome as one of the rare diseases most closely related to diabetes. The primary rationale for this is that, in this syndrome, diabetes serves as the catalyst for the subsequent complications experienced by those affected.	It is an interesting viewpoint to extrapolate results to other similar chronic diseases. So, in that way, it makes sense to include this suggestion in the discussion topic.
Methodology	The image appears cropped or the number 2 is misplaced.   When courses are placed in the image itself, it is reported that they have been obtained using AI.	It was corrected. Thank you.   No AI was used.
Discussion	The discussion would be improved by including a comparison of the results with other articles from different regions. Spain, France, etc	Very interesting comment. It was added results from Italy. However, it remains difficult to find results with T1DM adults and family functioning.
Conclusion	Having modified the previous point, it would be necessary to expand on the conclusions	Conclusion was expanded considering information added in discussion topic.

 

Reviewer 3 Report

Comments and Suggestions for Authors

Abstract
1.Some sentences are long and convoluted, such as:
  Diabetes Mellitus involves demanding challenges that interfere with family functioning…”
The message is diluted due to excessive qualifiers and embedded clauses. 

Introduction

1.The introduction cites numerous studies but lacks logical grouping. For instance, references [1] to [27] are presented continuously without clear transitions between topics (e.g., systemic theories, family impact, T1DM burden).

Reorganize the paragraph structure as follows:

• The common impact of T1DM on family functioning;

• The lack of research on adults with T1DM;

• The study’s rationale and objectives.

Methods

Participant recruitment methods are not described in detail (e.g., clinician referral or voluntary sign-up). The data collection setting and anonymity protocol are unclear, which may influence response bias.

Instruments

Although validated scales are used, the score interpretation is missing. For example, it is unclear whether higher or lower scores on SCORE-15 indicate better family functioning.

Statistical Analysis

The study appropriately employed K-means and two-step clustering for group identification and used binary logistic regression to examine predictors of metabolic control in adults with T1DM. While the statistical methods are well-chosen, the manuscript fails to report key model fit and predictive performance indicators, which limits the interpretability and credibility of the findings.

Specific Issues Identified:
Table 3 reports B coefficients and odds ratios (Exp(B)), but the following essential statistics are missing:

• Nagelkerke R² to reflect explained variance;

• Hosmer-Lemeshow test to assess model goodness-of-fit;

• AUC (Area Under the ROC Curve) to evaluate classification strength;

• Accuracy, sensitivity, and specificity to understand classification performance.

Data Collection

No mention of whether the questionnaire was completed anonymously or with standardized administration procedures, which may affect reliability and social desirability bias.

Results

Figures such as Figure 2 lack clear labels indicating group direction (e.g., higher = better functioning), and some tables are missing units or footnotes for clarification.
Add captions and labels, e.g.,
“Cluster 1 = MC group with high family functioning; Cluster 2 = NoMC group with low congruence and higher conflict scores.”

Conclusion

The conclusion overlaps with the discussion and lacks a strong statement about the study’s unique contribution or practical implications.

Suggestion:Strengthen the final paragraph:
“This is one of the first studies applying systems theory to adult T1DM care, highlighting the need for integrated family assessment in routine clinical practice.”

Implications & Recommendations

Recommendations such as implementing family-based interventions or training psychologists lack discussion on real-world feasibility (e.g., cost, personnel, time constraints).

Suggestion:Enhance recommendations with feasible steps, e.g.,
“Family functioning could be screened using the SCORE-15 by diabetes educators at intake, followed by referral to counseling if needed.”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comments on the Quality of English Language

The manuscript is written in generally comprehensible English and demonstrates a good understanding of academic style. However, the quality of the language can be further improved for clarity, conciseness, and sentence structure. Several sentences—particularly in the abstract, introduction, and discussion—are overly long or contain complex constructions that may reduce readability. Additionally, the use of transitions between ideas could be enhanced to improve the overall logical flow.

It is recommended that the authors seek professional English language editing or have the manuscript reviewed by a native English-speaking academic to refine grammar, improve coherence, and ensure terminology is consistently and appropriately used throughout.

Author Response

 

Response to reviewer 3 comments

 

Thank you for your accurate contributions considering the improving of study quality.

 

Introduction	Reorganize the paragraph structure as follows: The common impact of T1DM on family functioning; The lack of research on adults with T1DM; The study’s rationale and objectives.	Article introduction is organized as asked but it could not be clear to the first time reader. Therefore, it was clarified in each transition the main point. Thank you for your added value.   1) The common impact of T1DM on family functioning and the impact of family functioning on T1DM management.   Family assessment in adults with T1DM: Methodological challenges due to the Reciprocal impact family-disease (DM). The consequent impact in choosing appropriate methodology to catch this recursive circular causality in family assessment with the lenses of System Theory. There`s a impact of T1DM on family functioning but also the impact of family functioning in T1Dm management.   2) The lack of research on adults with T1DM;   The target population selection-  literature addresses this  approach  in T1DM, because literature is focused on parent-child relationships once T1DM onset is mostly on childhood or  T2DM  adults. but it lacks on T1DM adults.    Finaly the presentation of theoretical framework (Systems Theory) as a solution to encompass this methodological complexity.
Methods	Participant recruitment methods are not described in detail (e.g., clinician referral or voluntary sign-up)	Voluntary sign-up added at 2.1 topic.
Instruments	For example, it is unclear whether higher or lower scores on SCORE-15 indicate better family functioning.	In the results topic, last paragraph of point 3.1 refers to it. However, this information was now added at 2.4.2 – instrument description. That way, information will be more accessible and clear. Thank you.
Statistical analysis	The manuscript fails to report key model fit and predictive performance indicators, which limits the interpretability and credibility of the findings. Table 3 reports B coefficients and odds ratios (Exp(B)), but the following essential statistics are missing: Nagelkerke R² to reflect explained variance; Hosmer-Lemeshow test to assess model goodness-of-fit; AUC (Area Under the ROC Curve) to evaluate classification strength; Accuracy, sensitivity, and specificity to understand classification performance.	At the end of Table 3 that reports B coefficients and odds ratios (Exp(B)), are presented statistics namely Nagelkerke R² to reflect explained variance;
Data Collection	No mention of whether the questionnaire was completed anonymously	The questionnaire was completed in the presence of the interviewer. It was added at 2.3.
Results	“Cluster 1 = MC group with high family functioning; Cluster 2 = NoMC group with low congruence and higher conflict scores.”	Results are mentioned in the text before Figure  presentation.
Discussion	Enhance recommendations with feasible steps, e.g., “Family functioning could be screened using the SCORE-15 by diabetes educators at intake, followed by referral to counseling if needed	Thank you. It was added to recommendations.
Conclusion	“This is one of the first studies applying systems theory to adult T1DM care, highlighting the need for integrated family assessment in routine clinical practice.”	Thank you. It was added to the conclusions.

 

 

 

 

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have made a great effort to improve the article. All comments have been taken into account and I think the final work is very interesting and thought-provoking. The introduction, methodology, discussion and conclusions have been improved. Thank you for the effort.

Author Response

We appreciate your compliments and support.

Reviewer 3 Report

Comments and Suggestions for Authors

Your study addresses a timely and important topic, and your interdisciplinary approach is both commendable and innovative. With some targeted refinements—particularly in clarifying the introduction and enhancing the methodological transparency—this work has strong potential to make a valuable contribution to the literature on diabetes care and family systems.

1.The abstract should report specific quantitative findings (e.g., p-values, sample sizes, odds ratios) to improve scientific clarity and credibility.

1. Suggested structure for revising the Introduction:

   • Paragraph 1: Background and Known Facts
     Clearly explain that type 1 diabetes mellitus (T1DM) is a lifelong chronic disease that requires continuous self-management. This condition significantly impacts patients’ daily lives and family interactions. Introduce the Family Systems Illness Model (FSIM) to emphasize the critical role of family functioning in chronic illness care. Highlight that current clinical research tends to focus primarily on physiological indicators, while psychological and family-level dimensions are often overlooked.

   • Paragraph 2: Literature Review and Research Status
     Provide a concise overview of previous studies on family functioning, marital interaction, self-efficacy, and social support. Differentiate between research trends in adult T1DM and adult T2DM populations, and point out the limited representation of adult T1DM in the literature. Briefly comment on the strengths and limitations of commonly used instruments such as the SCORE-15 and the Congruence Scale.

   • Paragraph 3: Research Gap
     Emphasize that the “recursive interplay” between disease management and family dynamics in adults with T1DM remains insufficiently explored and lacks empirical integration. There is limited application of systemic models such as FSIM in the T1DM context, especially in studies that correlate family functioning with metabolic control indicators like HbA1c.

   • Paragraph 4: Purpose and Hypotheses
     Clearly state the study’s purpose: to investigate the associations among family functioning, quality of life, psychological congruence, and glycemic control in adults with T1DM. Specify the hypotheses—for example, that patients with poor metabolic control are expected to report higher levels of family conflict, and that emotional eating and dysfunctional family dynamics will significantly predict glycemic outcomes.

2. The term “recursive interplay” should be briefly defined in the abstract or early in the introduction to enhance conceptual clarity for readers.

3. A power analysis is missing from the Methods section. Please justify the adequacy of the sample size based on common statistical parameters such as effect size, power level, and significance threshold (alpha).

4. Please provide a rationale for using both K-means and two-step clustering. Explain how using both methods improves the robustness and reliability of the classification results.

5. The Results section is overly dense. It is recommended to restructure it according to Tables 1–4 and Figures 1–2. Use clear subheadings (e.g., “Cluster Classification,” “Family System Comparison,” “Predictors of Glycemic Control”) to improve logical flow and readability.

6. Some regression analyses lack confidence intervals. Please report 95% confidence intervals for all key variables and odds ratios in the regression outputs.

7. The Discussion section is overly broad. Focus on 3–4 major findings and highlight their theoretical and practical significance. Avoid excessive tangents or less relevant issues.

8. The Conclusion should provide concrete practical recommendations. For example, suggest incorporating family assessment tools into routine clinical care for adults with T1DM.

9. The reference formatting is inconsistent. Some entries are duplicated or not in APA style. Please revise the entire reference list to meet APA formatting guidelines and remove or consolidate repeated entries (e.g., Rolland, 1987 and 1994).

< !--a=1--> Comments on the Quality of English Language

The manuscript demonstrates an overall adequate level of academic English. Key terminology is used appropriately, and the sentence structures are generally grammatically correct. However, there are occasional issues with wordiness, awkward phrasing, and inconsistent use of tense or articles. The introduction section, in particular, would benefit from stylistic refinement and removal of redundant content to improve clarity and readability. A thorough language edit by a native English speaker or professional editor is recommended prior to publication.

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Author Response

We appreciate your detailed feedback. We are sure that the article is better in scientific rigor and clarity. 

Response to Reviewer 3 Comments point-by-point

The abstract should report specific quantitative findings (e.g., p-values, sample sizes, odds ratios) to improve scientific clarity and credibility.	Now, specific quantitative findings were  reported at abstract.
Suggested structure for revising the Introduction	Now, introduction is aligned with reviewer suggestions for each paragraph to improve scientific clarity. As a result, the order of the references had to be changed.
The term “recursive interplay” should be briefly defined in the abstract or early in the introduction	Now, it was briefly defined in abstract
A power analysis is missing from the Methods section. Please justify the adequacy of the sample size based on common statistical parameters such as effect size, power level, and significance threshold (alpha).	It was not reported, but the study sample size was estimated assuming 85% confidence level, a margin of error of 5%, population proportion of 10%, and a total population of 900 000 adult people with diabetes in Portugal (according to IDF -Internatiobal Diabetes Federation).  At least 75 individuals was needed.
Please provide a rationale for using both K-means and two-step clustering. Explain how using both methods improves the robustness and reliability of the classification results	Explanation for this methodological option was made in 2.6 data Analysis: «Instead of one multivariate method, we calculated K-means and two-steps algorithms so that consistent results could be achieved, as proposed by Kos and Psenicka [75]»   But now it was added: «If a two groups classification is found and replicated with a different method, a two-clusters solution to diabetic groups bipartition is reinforced. »
The Results section is overly dense. It is recommended to restructure it according to Tables 1–4 and Figures 1–2. Use clear subheadings (e.g., “Cluster Classification,” “Family System Comparison,” “Predictors of Glycemic Control”) to improve logical flow and readability.	Now, clear Subheadings were introduced as asked.     Figure 1 and Table 1 belong to conceptual understanding (introduction) and sociodemographic variables (methods and materials), respectively. The Results section is presented following an order and logic sequence of results presentation from figures (2) to tables (2-4). -Cluster classification (that presents a bipartition – group formation) - So, what Group differences (NoMc versus MC) - And what Predictors of one of the groups – no metabolic control - Marital functioning (specific result – subgroup of participants)
Some regression analyses lack confidence intervals. Please report 95% confidence intervals for all key variables and odds ratios in the regression outputs	Regression outputs -            Confidence intervals 95% confidence intervals for all key variables are reported in regression analyses.
The Discussion section is overly broad. Focus on 3–4 major findings and highlight their theoretical and practical significance. Avoid excessive tangents or less relevant issues	Discussion is divided according to the three main conclusions and now presentation clarity with theorical and practical significance is mentioned. 1-       Cluster bipartition 2-       Group differences 3-       Intervention implications Limitations and future studies
The Conclusion should provide concrete practical recommendations. For example, suggest incorporating family assessment tools into routine clinical care for adults with T1DM.	In conclusion section, «highlighting the need for integrated family assessment in routine clinical practice» was replaced by «incorporating family assessment tools, as SCORE-15, «into routine clinical care for adults with T1DM.»
The reference formatting is inconsistent. Some entries are duplicated or not in APA style. Please revise the entire reference list to meet APA formatting guidelines and remove or consolidate repeated entries (e.g., Rolland, 1987 and 1994).	Thank you. In fact, the last three references were not aligned with editorial references guidance (they were added in the last revision round).In relation to Rolland, there are four different references, but the same author.
The manuscript demonstrates an overall adequate level of academic English. Key terminology is used appropriately, and the sentence structures are generally grammatically correct. However, there are occasional issues with wordiness, awkward phrasing, and inconsistent use of tense or articles. The introduction section, in particular, would benefit from stylistic refinement and removal of redundant content to improve clarity and readability. A thorough language edit by a native English speaker or professional editor is recommended prior to publication.	As asked, changes were made to significant parts of the introduction, and other article topics. Specific word modification was also made.   Before submission, this article was revised by an English partnership of research projects in University - Scott Culp.