Distal technologies impact, Telehealth and mHealth, on type 1 diabetes self-management: a narrative review

Aim To evaluate the possible influences of new technologies on quality of life, disease and complications management (self-management) in children, teenagers and young adults with type 1 diabetes mellitus (T1DM). Research design Narrative review. Materials and methods We performed a research through scientific/medical database: PubMed, Cinahl, The Cochrane Library, Proquest Central, Phych INFO and UpToDate, applying the following filters: studies in humans, English language and most recent publication (from 2007 to 2017).Only those responding to the following selection criteria have been selected: 1. Quantitative studies. 2. Use of quantitative evaluation tools, monitoring quality of life and self-management. 3. Reference population of age group less than 65 years old. 4. Focus on usefulness, satisfaction and technologies influence on quality of life and disease self-management of T1DM subjects (outcomes). Results Among the selected articles, only 7 were fitting the inclusion criteria of this review. Overall, despite some studies did not show significant differences in quality of life, results showed an increased frequency in Self Monitoring Bloog Glucse (SMBG) and an improved metabolic control with the use of new technologies, especially in young teenagers with T1DM. Conclusion The different studies showed the potential advantages and the overall feasibility of using new apps on mobile technologies, that appear to be mostlyeffective in young teenagers affected by chronic disease, such as T1DM. These data suggest to identify new effective and acImpatto delle tecnologie distali, Telehealth e mHealth, sul self management del diabete di tipo 1: una revisione narrativa Distal technologies impact, Telehealth and mHealth, on type 1 diabetes self-management: a narrative


BACKGROUND
Type 1 diabetes mellitus (T1DM) is the most common and severe childhood metabolic disorder. Its incidence is constantly increasing all over the world (1) .
Diabetes is a complex chronic disease that can result in serious acute and chronic complications. The adherence to SMBG in the contest of disease self-management can be very complex and demanding mostly for children and teenagers (2) . Since adolescence is  (2) .
New communication modalities are entering the daily routine and are increasingly used as educational systems for patients affected by chronic disease.
Sometimes these tools have become even more important and useful than direct contact, because they allow to interact with people, for example teenagers, who otherwise have adopted refusal attitudes and denial about rules. Therefore, it is pivotal to know and examine all technological innovations in order to apply the most suitable one to a specific patient and context (3) . The impact of such technologies on quality of life has also to be considered, in fact it is an increasingly recognized variable that affects psychosocial health in young T1DM patients affected (1) .
Diabetes management is an application area where mobile devices could improve quality of life for people living with chronic diseases (4) , especially mobile phones, that for they wide use, can potentially help diabetes daily management through the creation of an active interaction between patients and health-Impatto delle tecnologie distali, Telehealth e mHealth, sul self management del diabete di tipo 1: una revisione narrativa care providers (5) . Thus, compared to the first-generation mobile phones, today smartphones and tablet PC offer a wide range of functions, even in the   medical field,where several available applications   support disease management, promoting health and well-being awareness (6) .
At this regard, Arnhold's et al. (2014) showed that numerous applications are already available to helpboth type 1 and type 2 diabetes management, with the number of health-related applications increasing up to 31.000 in 2013 (6) . Some studies present a diabetes mobile applications in-depth analysis, which shows in the first place that personalized education is only in some applications (4) .
However, in despite of the considerable amount of diabetes mobile applications currently available, most of these offer only a limited number of personalized features. In fact, it is increasingly difficult for users to find an application that suits their needs (6) .
The ideal one would be a multifunctional application that could simultaneously inform and advice patients through scientificdocumentation, reminder and counseling functions, an application that may be particularly useful in recently diagnosed T1DM patients. In addition, patients and healthcare providers should be directly involved during the application development to address practical usage, revealing issue needs for their diabetic followers (6) .
Another issue highlighted by Baron's et al. (2012) is the importance of remote data recording and monitoring, also called mobile telemonitoring (mobile Health) (7) . Thanks to the development of mobile devices and wireless technologies, patients could transmit real time data, at any time and anywhere, which may help in the management of chronic diseases, that require an intensive daily monitoring (6) .
Accordingly, many studies showthat glucose values measured in real time automatic transmission from the measuring device to mobile device is an important driver to promote ease of useand consequently patient's adherence (6) . Furthermore, some manufacturers already offer glucose meters that allow measuring blood glucose values in real time, with the transmission via Bluetooth to a mobile device, simplifying documentation process for the patient and, at the same time, increasing reliability of the entered data and the subsequent analysis.
However, wireless technology use in health care has been primarily evaluated as a telemedicine tool and patient orientation is still under development (8) .
These new monitoring methods (such as applications or website that help monitor food intake, glucose levels, controls and other significant parameters) in T1DM management have been well accepted ensuring good decision-making processes, efficiency and adhesion to treatment (9) .
Gimènez-Perez's et al. (2002) study assessed how the use of internet affects knowledge and well-being of the patient, stating that internet advent will probably change the way healthcare will be carried out.
Currently, its impact is particularly compromised by access rate and internet use for health purpose, but due to their high rate of ownership and use, mobile phones will be an important promise as a tool in health communication technologies (8) . Among the many studies examined, in this regard, a meta-analysis by Liang's et al. (2011) has shown that mobile phone intervention methods for diabetes treatment have led to significant improvements in glycemic control and self-management (5) . Mobile devices use, data recording and monitoring could be also the key factor to increase patients'awareness and motivation in diabetes management (7) . In this regard, Guo

MATERIALS AND METHODS
Literature research was conducted via PICO method and the use of predefined and specific keywords within the databases. During the research, abbreviations related to the topic were considered, such as SMBG (Self-monitoring blood glucose), HbA1c (hemoglobin glycated), Telemedicine and mHealth (MobileHealth).
• I (intervention) = Technologies evaluation for SMBG and management.
• O (outcomes) = Improvement in self-management and quality of life.
Impatto delle tecnologie distali, Telehealth e mHealth, sul self management del diabete di tipo 1: una revisione narrativa Articles were selected according to these criteria: • Quantitative studies.
• Use of quantitative tools to evaluate and monitor quality of life and self-management.
• Reference population of age group less than 65 years old.
• Study focus on utility, satisfaction and technologies influence on quality of life and disease self-management of those affected by type 1 diabetes mellitus (outcomes).

Databases research guided by different keywords
combinations identified scientific articles abstracts that were relevant based on: • Comparison between new mobile technologies (smartphones, tablet, PC, app, software) and glycemic measuring standard method (SMBG).
• New technology impact on glycemic monitoring, type 1 diabetes management, chronic disease self-management and quality of life.

REFERENCES LINK
PubMed 1) Type 1 diabetes AND self-management AND smartphone application AND mobile health.
3) Ttype 1 diabetes AND telemedicine AND software.  1) Type 1 diabetes AND self-management AND quality of life AND mobile application.
2) Type 1 diabetes AND self-management AND telemedicine AND quality of life.

REFERENCES LINK
PubMed   Outcomes evaluation times also differ among the studies: from 12 weeks (12) to more than 18 months (11) .  The analysis encompassed a period of ten years, from 2007 (10) to 2017 (11) , from simple reminder softwares to a self-management tool, and then up to sophisticated automatic calculator softwares of carbohydrate and insulin bolus, such as Diabeo system (13) and DID system (14) . highlighted the potential of smartphones through applications as Glucose Buddy, which uses a text-message feedback system sent from an expert in order to improve glycemic control and consequently reduce HbA1c values (15) . The different telemedicine systems used have evolved simplifying self-management process more and more, making available data and graphs in real time and everywhere, promoting the close collaboration between patients and healthcare professionals thanks to direct feedback systems.
In conclusion, available data indicate that, in Impatto delle tecnologie distali, Telehealth e mHealth, sul self management del diabete di tipo 1: una revisione narrativa