The initial bibliographic search yielded 798 articles, of which 23 duplicates were eliminated. Subsequently, 56 articles were selected for title and Abstract. After their complete reading, 39 were discarded because they did not meet the inclusion criteria. Finally, 17 articles were selected, of which 10 were discarded for their low methodological quality (Table 1). Thus the final selection included seven systematic reviews (Figure 1).
Table 1. Quality assessment of systematic reviews through Amstar-2
|
ítems
Amstar-2
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
9
|
10
|
11
|
12
|
13
|
14
|
15
|
16
|
Methodological Quality
|
McMillan, 2017 [13]
|
YES
|
NO
|
YES
|
YES PARTIAL
|
NO
|
NO
|
YES
|
YES
|
YES PARTIAL
|
YES
|
NA
|
NA
|
NO
|
NO
|
NA
|
YES
|
Low
|
Pal, 2013 [14]
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
High
|
Fu, 2017 [17]
|
YES
|
NO
|
YES
|
YES PARTIAL
|
NO
|
NO
|
YES PARTIAL
|
YES PARTIAL
|
NO
|
NO
|
NA
|
NA
|
NO
|
NO
|
NA
|
NO
|
Low
|
Porter, 2016 [27]
|
YES
|
YES PARTIAL
|
YES
|
YES PARTIAL
|
YES
|
NO
|
YES
|
YES
|
YES PARTIAL
|
NO
|
NA
|
NA
|
YES
|
YES
|
NA
|
NO
|
Moderate
|
Anderson, 2016 [37]
|
NO
|
NO
|
YES
|
YES PARTIAL
|
NO
|
NO
|
YES PARTIAL
|
YES PARTIAL
|
NO
|
NO
|
NA
|
NA
|
NO
|
NO
|
NA
|
YES
|
Very low
|
Hou, 2016 [38]
|
YES
|
NO
|
YES
|
YES PARTIAL
|
YES
|
YES
|
YES
|
YES PARTIAL
|
YES PARTIAL
|
NO
|
YES
|
YES
|
NO
|
YES
|
YES
|
NO
|
Baja
|
Cotter, 2014 [39]
|
NO
|
NO
|
NO
|
YES PARTIAL
|
YES
|
YES
|
YES
|
YES
|
NO
|
YES
|
NA
|
NA
|
NO
|
YES
|
NA
|
YES
|
Very low
|
David, 2016 [40]
|
NO
|
NO
|
YES
|
NO
|
NO
|
NO
|
YES
|
YES
|
NO
|
NO
|
NA
|
NA
|
NO
|
NO
|
NA
|
NO
|
Very low
|
Bonoto, 2017 [41]
|
YES
|
NO
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
NO
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
Moderate
|
Drincic, 2016 [42]
|
YES
|
NO
|
YES
|
NO
|
NO
|
NO
|
NO
|
YES
|
NO
|
NO
|
NA
|
NA
|
NO
|
NO
|
NA
|
NO
|
Very low
|
El-Gayar, 2013 [43]
|
YES
|
NO
|
NO
|
YES PARTIAL
|
YES
|
NO
|
YES
|
YES PARTIAL
|
NO
|
NO
|
NA
|
NA
|
NO
|
NO
|
NA
|
NO
|
Very low
|
Hood, 2016 [44]
|
NO
|
NO
|
NO
|
NO
|
NO
|
NO
|
NO
|
YES
|
NO
|
NO
|
NA
|
NA
|
NO
|
NO
|
NA
|
YES
|
Very low
|
Veazie, 2018 [45]
|
YES
|
NO
|
YES
|
YES PARTIAL
|
YES
|
NO
|
YES
|
YES PARTIAL
|
YES PARTIAL
|
YES
|
NA
|
NA
|
YES
|
YES
|
NA
|
YES
|
Moderate
|
Aminuddin, 2019 [46]
|
NO
|
YES
|
NO
|
YES
|
YES
|
NO
|
NO
|
YES PARTIAL
|
NO
|
YES
|
NO
|
NO
|
NO
|
NO
|
NO
|
YES
|
Very low
|
Akbari, 2019 [47]
|
NO
|
NO
|
YES
|
YES PARTIAL
|
YES
|
YES
|
YES PARTIAL
|
YES PARTIAL
|
YES
|
NO
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
Moderate
|
Lunde, 2018 [48]
|
YES
|
YES PARTIAL
|
YES
|
YES PARTIAL
|
YES
|
YES
|
YES PARTIAL
|
NO
|
YES PARTIAL
|
NO
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
Moderate
|
Wu, 2019 [49]
|
NO
|
NO
|
YES
|
YES
|
YES
|
YES
|
YES PARTIAL
|
YES PARTIAL
|
YES PARTIAL
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
YES
|
Moderate
|
1 Did the research questions and inclusion criteria for the review include the components of PICO? 2 Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol? 3 Did the review authors explain their selection of the study designs for inclusion in the review? 4 Did the review authors use a comprehensive literature search strategy? 5 Did the review authors perform study selection in duplicate? 6 Did the review authors perform data extraction in duplicate? 7 Did the review authors provide a list of excluded studies and justify the exclusions? 8 Did the review authors describe the included studies in adequate detail? 9 Did the review authors use a satisfactory technique for assessing the risk of bias in individual studies that were included in the review? 10 Did the review authors report on the sources of funding for the studies included in the review? 11 If meta-analysis was performed did the review authors use appropriate methods for statistical combination of results? 12 If meta-analysis was performed, did the review authors assess the potential impact of risk of bias in individual studies on the results of the meta-analysis or other evidence synthesis? 13 Did the review authors account for risk of bias in individual studies when interpreting/ discussing the results of the review? 14 Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review? 15 If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review? 16 Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
NA=Not applicable.
|
Characteristics and quality of the systematic reviews
The main characteristics of the seven systematic reviews included in this review are shown in Table 2. The complete analysis of their methodological quality is found in Table 1.
Although differences were observed in search methods, databases, inclusion and exclusion criteria, data extraction, quality assessments and statistical analyses, the seven systematic reviews generally provided an extensive description of the used methods, as well as the quality and general characteristics of the studies they included.
The studies included in the seven systematic reviews were conducted mainly in the United States, Asia and Europe. When we analyzed the original studies included in the reviews, we considered that 28 studies appeared in more than one systematic review.
The number of studies included in each analyzed review fell within the 8-19 range. In all cases, except for one study with a cross design featured in the review by Porter et al. [27], random clinical trials (RCTs) were included which assessed interventions based on using Apps to manage DM in adult patients. Interventions lasted between 1 and 12 months. The vast majority of the studies analyzed HbA1c as the primary outcome measure, which was also used to perform a meta-analysis in the reviews by Pal et al. [14], Bonoto et al. [41], Lunde et al. [48] and Wu et al. [49].
Table 2. General characteristics of the included systematic reviews
First author, year / source
|
Search strategy
|
No. studies included / Total no. of participants
|
Objective
|
Population
|
Intervention
|
Comparison
|
Outcome measures
|
Time
(months)
|
Quality
|
Pal, 2013 14
/
Cochrane Database of Syst Rev
|
Cochrane Library, MEDLINE, EMBASE, PsychINFO, Web of Science, CINAHL; + 3 databases for thesis
Indicated search terms.
No restrictions with publishing date and language.
|
16 RCT
/
3.578
|
Evaluate the effect of DM self-control interventions based on computer tools about health status and CVRS.
|
DM2
≥ 18 years
|
Apps to help patients acquire knowledge, skills (lifestyles) and emotional self-control emotional (handling stress, anxiety and social support).
|
Usual healthcare
|
Primary:
CVRS (N=5)
HbA1c (N=16)
Death by any cause (N=2)
Secondary:
Cognitive faculties: knowledge/ comprehension (N=4); self-efficacy (N=2)
Habits: physical activity (N=5); diet (N=6)
Social help (N=2)
PAS and PAD (N=5)
Lipid profile (N=10)
BMI/kg (N=5)
Anxiety or depression (N=6)
Complications (N=0)
Adverse effects (N=1)
|
1-12
|
High
|
Porter, 2016 27
/
Nutrients
|
Ovid MEDLINE, EMBASE, CINAHL, EBM Reviews Cochrane Database of Systematic Reviews, PsycINFO, EBM Reviews-Health Technology Assessment.
Indicated search terms.
No restrictions with publishing date and language.
|
9 (N=8 RCT + N=1 Crossed)
/
1.234
|
Determine the effect of using Apps designed to record the intake of food or nutrients on controlling DM and nutritional outcomes.
|
DM1
DM2
≥ 18 years
|
Apps for recording food intake, glycemia, physical activity and medication.
|
Usual healthcare
|
Primary:
HbA1c (N=9)
Secondary:
Glycemia on an empty stomach (N=4)
BMI/kg/anthropometry (N=6)
Lipid profile (N=5)
Diet (N=2)
Satisfaction and usefulness (N=4)
Acceptance and commitment (N=5)
|
3-12
|
Moderate
|
Bonoto, 2017 41
/
JMIR Mhealth Uhealth
|
MEDLINE, Cochrane Library (CENTRAL), LILACS.
Indicated search terms.
Publishing date 2008-2016.
No language restrictions.
|
13 RCT
/
1.263
|
Evaluate the effectiveness of Apps as a healthcare support.
|
DM1
DM2
≥ 18 years
|
Apps that works as an automatic reminder to help adhere to DM self-control measures (glycemia, weight, medication, food, physical activity).
|
Usual healthcare
|
Primary:
HbA1c (N=12)
Hypogycemia episodes (N=5)
Secondary:
Glycemia on an empty stomach (N=4)
Body weight (N=6)
SBP and DBP (N=4)
Lipid profile (N=3)
Quality of life/satisfaction (N=6)
|
1-12
|
Moderate
|
Veazie, 2018 45
/
J Gen Intern Med
|
Ovid MEDLINE, Cochrane Database of Systematic Reviews.
No indicated search terms.
Publishing date January 2008-June 2017.
Restricted to the English language.
|
15 (N=13 RCT + N=2 Subgroup RCT)
/
ne
|
Examine the characteristics, clinical efficacy and usability of Apps for DM self-management
|
DM1
DM2
≥ 18 years
|
Apps to improve diabetes self-control (social support, education, reminder of activities, recording glycemia, medication, patient-professional communication).
|
Usual healthcare
|
Primary:
HbA1c
Hypo/hyperglycemia episodes
Glycemia on an empty stomach
BP
Lipid profile
BMI/kg/anthropometry
Diabetic symptoms
Quality of life
Stress/depression
Satisfaction and usefulness
Self-care and self-efficacy
|
2,5-12
|
Moderate
|
Akbari, 2019 47
/
Diabetes Metab Syndr
|
PubMed, EMBASE, Web of Science, Cochrane Library Databases.
Indicated search terms.
No restrictions with publishing date and language.
No publishing date restrictions
|
9 RCT
/
997
|
Evaluate the effect of “m-health” on the lipid profile of patients with metabolic syndrome and obesity, DM or heart disease
|
DM1
DM2
≥ 18 years
|
Apps to improve e lipid profile through healthy life habits (physical activity, food, emotional support, medication, smoking).
|
Usual healthcare
|
Primary:
Lipìd profile
|
3-12
|
Moderate
|
Lunde, 2018 48
/
J Med Internet Res
|
EMBASE, MEDLINE, CINAHL, Academic Research Premier, Cochrane Reviews and Trials.
Indicated search terms.
Publishing date before 23/02/17.
Restricted to the English language.
|
8 RCT
/
1.201
|
Revise the effectiveness of interventionsbased on Apps that lasted a minimum of 3 months to promote changes in lifestyles.
|
DM1
DM2
≥ 18 years
|
Apps to monitor glycemia, BP and/or diet habits
|
Usual healthcare
|
Primary:
HbA1c (N=8)
BMI/kg (N=6)
Abdominal girth (N=3)
Quality of life (N=3)
Habits: physical activity (N=1); diet (N=1)
|
3-12
|
Moderate
|
Wu, 2019 49
/
JMIR Mhealth Uhealth
|
Cochrane Central Register of Controlled Trails in the Cochrane Library, MEDLINE, EMBASE, CINAHL, PsyscINFO.
Indicated search terms.
Publishing date 01/01/06-14/05/18.
No language restrictions
|
19 RCT
/ 1.605
|
Summarize existing clinical evidence for the efficiency of Apps to modify lifestyles in different DM types.
|
DM1
DM2
≥ 18 years
|
Apps to help to improve lifestyles (physical activity, food, medication, education).
|
Usual healthcare
|
Primary:
HbA1c (N=16)
Secondary:
Lipid profile (N=7)
SBP and DBP (N=10)
Change in treatment (N=3)
Anxiety or depression (N=4)
BMI/kg (N=11)
Quality of life/satisfaction (N=5)
Knowledge/self-care (N=9)
Abdominal girth (N=7)
Habits: physical activity (N=6); diet (N=2)
Complications (N=1)
|
3-12
|
Moderate
|
No: Number / DM1: Type 1 Diabetes Mellitus / DM2: Type 2 Diabetes Mellitus 2 / ns: Not specified / RCT: random clinical trial / BP: Blood pressure / SDP: systolic blood pressure / DBP: diastolic blood pressure / BMI: body mass index / HbA1c: glycated hemoglobin / kg: Kilograms of body weight /HRQOL: health-related quality of life.
|
|
|
|
|
|
|
|
|
|
|
|
Mobile applications and the lifestyles they address
The identified mobile Apps and lifestyles are provided in detail in Table 3.
Twenty-three different apps were identified. The only App that was included in all seven systematic reviews was “BlueStar Diabetes”, which offers free access for Apple and Android, and addresses food. We were unable to identify the commercial name of one App.
Regarding the lifestyles covered by Apps, eight included different questions about DM self-control in relation to food, five to physical activity, and 10 combined both these components.
Most research into the effectiveness of Apps was conducted with individuals with DM2. Although their effectiveness for DM1 was also studied, no systematic reviews included studies about Gestational Diabetes (GD).
Table 3. The mobile applications included and the lifestyles they address
App
|
Systematic Review
|
Operating system
|
DM type
|
Lifestyle
|
Cost
|
Bees
|
Veazie, 2018 45
|
Apple/Android
|
DM1
|
Physical activity and food
|
Free
|
BlueStar Diabetes
|
Pal, 2013 14 / Porter, 2016 27 / Bonoto, 2017 41 / Veazie, 2018 45 / Akbari, 2019 47 / Lunde, 2018 48 / Wu, 2019 49
|
Apple/Android
|
DM2
|
Food
|
Free
|
CollaboRhythm
|
Bonoto, 2017 41
|
ns
|
DM2
|
Physical activity and food
|
ns
|
Connected Wellness Platform
|
Lunde, 2018 48 / Wu, 2019 49
|
Android
|
DM2
|
Physical activity and food
|
ns
|
Diabeo Telesage
|
Bonoto, 2017 41 / Veazie, 2018 45 / Wu, 2019 49
|
Apple/Android
|
DM1
|
Physical activity and food
|
Free
|
Diabetes Diary
|
Veazie, 2018 45 / Wu, 2019 49
|
Apple/Android
|
DM1
|
Food
|
Free
|
Diabetes diet advisor
|
Pal, 2013 14
|
ns
|
DM2
|
Food
|
ns
|
Diabetes Interactive Diary (DID)
|
Porter, 2016 27 / Bonoto, 2017 41 / Veazie, 2018 45 / Akbari, 2019 47 /Wu, 2019 49
|
Android
|
DM1
|
Food
|
Free
|
Diabetes Pilot ™
|
Porter, 2016 27
|
Apple
|
DM2
|
Food
|
Payment
|
Diabetes Under Control (DBEES)
|
Bonoto, 2017 41 / Porter, 2016 27
|
Apple/Android
|
DM1
|
Physical activity and food
|
Free
|
DialBetics
|
Porter, 2016 27 / Akbari, 2019 47 / Lunde, 2018 48 / Wu, 2019 49
|
ns
|
DM2
|
Physical activity and food
|
ns
|
eCoFit
|
Wu, 2019 49
|
Android
|
DM2
|
Physical activity
|
Free
|
Few Touch Application (FTA)
|
Bonoto, 2017 41 / Porter, 2016 27 / Lunde, 2018 48 / Wu, 2019 49
|
ns
|
DM2
|
Physical activity and food
|
ns
|
FoodLog
|
Porter, 2016 27 / Akbari, 2019 47 / Lunde, 2018 48 / Wu, 2019 49
|
ns
|
DM2
|
Physical activity and food
|
ns
|
Gather Health
|
Veazie, 2018 45
|
Apple/Android
|
DM2
|
Physical activity and food
|
Free
|
Glucose Buddy
|
Bonoto, 2017 41 / Veazie, 2018 45 / Wu, 2019 49
|
Apple/Android
|
DM1
|
Physical activity and food
|
Free
|
LiFe!
|
Wu, 2019 49
|
Android
|
DM2
|
Physical activity
|
Free
|
mDiab
|
Veazie, 2018 45
|
Apple/Android
|
DM2
|
Physical activity
|
Payment
|
METADIETA
|
Bonoto, 2017 41
|
Apple/Android
|
DM2
|
Food
|
Payment
|
Monica
|
Bonoto, 2017 41 / Lunde, 2018 48 / Wu, 2019 49
|
Android
|
DM2
|
Physical activity
|
ns
|
NICHE
|
Wu, 2019 49
|
ns
|
DM2
|
Physical activity
|
Free
|
WellTang
|
Porter, 2016 27 / Veazie, 2018 45 / Akbari, 2019 47 / Lunde, 2018 48 / Wu, 2019 49
|
Apple
|
DM1/DM2
|
Food
|
Free
|
ne
|
Wu, 2019 49
|
ns
|
DM2
|
Food
|
ns
|
App: Mobile Aplication / DM1: Type 1 Diabetes Mellitus / DM2: Type 2 Diabetes / ns: Not specified
|
Primary outcome measures
Pal et al. [14] performed a meta-analysis of the 11 studies, which provided sufficient data on HbA1c levels. They found statistically significant differences between the results of the intervention groups and the control groups, with lower HbA1c values in the intervention subjects. The impact of the intervention was significantly stronger (P <.001) in the three studies that used mobile phones, with an effect on HbA1c of -5,5 mmol/mol or ‑0.5% (95%CI: -0.74 to -0.26; P=.59; I²=0%). However, the effects of interventions seemed to disappear with time as the analysis of the results of the studies with a duration equal to or longer than 6 months was not statistically significant.
In four of the nine studies they analyzed, Porter et al. [27] found a statistically significant improvement in HbA1c of diabetics in the intervention group compared to the control group, while the other studies observed no significant differences between the two groups.
In the review by Bonoto et al. [41], in six of the 12 studies that included HbA1c values, a statistically significant difference was found in the reduction of this parameter in favor of intervention groups. Likewise, the meta-analysis carried out in this review showed the effectiveness of using mobile applications to control diabetes, with an average difference of -0.44% (95%CI: 0.59 to -0.29; P<.10; I²=32%), which was statistically significant (P<.001).
Veazie et al. [45] identified two Apps to control DM1 (Glucose Buddy and Diabeo Telesage) and three others for DM2 (Gather Health, BlueStar and WellTang), whose use demonstrated better statistics and clinical significance for HbA1c than the control groups (CG).
Lunde et al. [48] included three studies to evaluate the effectiveness of short-term apps, and four long-term studies. The result was a significant decrease in HbA1c in both cases, although the quality of the evidence was poor for the short-term and moderate for the long-term Apps.
However, Wu et al. [49] did not reveal any significant difference in HbA1c between the intervention group and control group with DM1, in both the short - 0.09% (95%CI: 0.34 to -0.15; P=.18; I²=39%) and long term - 0.21% (95%CI:‑0.52 a -0.09; P=.17; I²=64%) terms. In the Apps that addressed patients with DM2, a statistically significant difference appeared in both the short and long terms with 0.35% (95% CI: ‑0.48 to -0.21; P<0.01; I²=0%).
To assess the effect of interventions based on using Apps on diabetic patients’ healthy lifestyles, we also analyzed changes in body weight or BMI as a result of the intervention. Lunde et al. [48], included three studies in which the IG reduced weight significantly [50-52]. In the review by Pal et al. [14], only two of the five studies using mobile devices in their interventions reported changes in body weight and BMI [51,54]. However, these authors found no significant differences between the intervention groups and control groups. Bonoto et al. [41] did not observe any significant differences in their combined analysis of the results of four studies with data on changes in participants' body weight [mean difference: -0.39 (95%CI: -1.43 to 0.66; P=.47; I²=0%)]. Similarly in their review, Porter et al. [27] described that none of the six studies with body weight or BMI data found significant changes linked with the intervention. Only one study indicated a slight reduction in the BMI of all the groups, but did not provide any data [53]. Finally, none of the participants in the studies analyzed by Veazie et al. [45] reported improvements in body weight or BMI.
Secondary Outcome Measures
Health-related quality of life (HRQL) was analyzed as a secondary outcome measure of interventions based on the use of Apps. Of the 16 studies included in the review by Pal et al. [14], five provided results on HRQL. However, these authors did not observe any significant improvement in the HRQL of the intervention subjects compared to the control subjects. Bonoto et al. [41] found that three studies yielded positive and statistically significant changes in both the quality of life of and satisfaction with the treatment of the patients in the intervention group. The improvements reported by the participants using Apps included perceiving hyperglycemia episodes, social relationships, feeling less fear of hypoglycemia and that Apps helped them to control their treatment and to maintain healthier dietary habits [54-56]. Conversely, Veazie et al. [45] found no evidence for improvement in the quality of life of the diabetic patients who used mobile Apps.
Some of the studies included in the seven analyzed reviews provided results on the lipid profile of diabetic subjects, which may be related to changes in their dietary habits and lifestyles. In connection with this, Pal et al. [14] carried out a meta-analysis with data from seven studies and found that the effect of the intervention on the participants’ lipid profile was not significant (P = .17), with a mean difference to the control group of -0.11 (95%CI:-0.28 to 0.05; P=.03; I²=57%). A significant improvement in the lipid profile was observed in only one intervention study based on using mobile devices, specifically a reduction in TC, LDL-C and TG levels. Bonoto et al. [41] and Akbari et al. [47] also found no significant differences in their meta-analysis of TC, HDL-C, LDL-C and TG levels. Porter et al. [27] and Veazie et al. [45] identified one study which observed a significant lowering (P = .04) of triglyceride levels, but not the remaining lipids, in the participants who used a mobile app to control DM1 (Diabetes Interactive Diary) [55].
Regarding changes in diabetic patients’ blood pressure, one study included in the review by Pal et al. [14] found a statistically significant decrease in SBP (127±14 mmHg to 120±19 mmHg; P=.001) and DBP (78±10 mmHg to 74±8 mm Hg, P<.001) in the intervention group [57]. Bonoto et al. [41] did not observe any significant differences for the intervention and control groups of four studies in participants' SBP and DBP. Similarly, no intervention analyzed in the review by Veazie et al. [45] revealed participants’ improved blood pressure.
Finally in a combined analysis of fasting blood glucose results from four studies, Bonoto et al. [41] reported no significant differences between the intervention and control groups. In the review by Porter et al. [27], two studies described a significantly more marked reduction (P <.01) in fasting blood glucose levels for the intervention group than for the control group [56,59], while two other studies did not observe any significant differences between these two groups [56,58]. Veazie et al. [45] identified one app (WellTang), whose use for DM2 demonstrated better fasting blood glucose values than for the control subjects.
Adverse effects of interventions
One important aspect to bear in mind when assessing the efficiency of Apps designed to improve DM self-control is that adverse effects may appear.
Of all the studies included in the seven reviews analyzed herein, a few describe adverse reactions reported by the participants of the intervention groups. Pal et al. [14] found a non significant increase in the frequency of mild hypoglycemia episodes in the intervention group, with no differences in severe or nocturnal hypoglycemia episodes [54]. Five studies included in the review by Bonoto et al. [41] reported hypoglycemia episodes. One reports averages of 30 and 33 mild episodes in the the intervention and the control group, respectively, and a severe episode in the control group [56]. In three other studies, no significant differences were observed between groups [55,60,61]. In a fifth study, the relative risk of severe hypoglycemia episodes was lower in IG (0:14; 95%CI: 0.07-0.029) [54]. One of the studies in the review by Wu et al. [49] found no statistically significant differences between the hypoglycemic events of IG and CG [56]. Two mobile apps (Diabetes Diary and Diabetes Interactive Diary) reviewed by Veazie et al. [45] showed improvements in hypoglycemic episodes of DM1.
Regarding adverse psychological effects, such as stress, anxiety or depression, Wu et al. [49] described a significant improvement in anxiety and depression symptoms in four studies [52,62-64].