JMIR Publications

ABSTRACT

Background:

Digital interventions offer scalable alternatives to traditional face-to-face diabetes education but often face challenges related to inconsistent clinical effectiveness, declining user engagement, and reliance on passive features such as reminders. Integrating behavioral nudge strategies into digital education platforms may strengthen sustained self-management by supporting both reflective decision-making and automatic behavior regulation.

Objective:

To evaluate the effectiveness of a digital structured education program augmented with behavioral nudge tools in improving metabolic, behavioral, and psychological outcomes among adults with type 2 diabetes.

Methods:

This multicenter randomized controlled trial was conducted in the endocrinology departments of four hospitals in China. Adults with type 2 diabetes were randomly assigned to an intervention group receiving digital structured education integrated with behavioral nudge tools (n=146) or a control group receiving standard digital diabetes education without nudges (n=147). Assessments were conducted at baseline and 12-week follow-up. The primary outcome was HbA1c at 12 weeks, adjusted for baseline HbA1c and study center. Secondary outcomes included fasting blood glucose, body weight, body mass index, waist circumference, blood pressure, lipid profiles, self-management behaviors, self-efficacy, and habit strength.

Results:

Among 293 participants (mean [SD] age, 49.10 [10.02] years), 287 (97.9%) completed follow-up. At 12 weeks, the intervention group demonstrated significantly greater improvements than the control group in HbA1c (−0.38%; 95% CI −0.68% to −0.09%, P=0.011), fasting blood glucose (−0.75 mmol/L; 95% CI −1.27 to −0.44 mmol/L, P＜0.001), body weight (−0.84 kg; 95% CI −1.61 to −0.07 kg, P=0.033), body mass index (−0.38 kg/m²; 95% CI −0.65 to −0.11 kg/m², P=0.006), systolic blood pressure (−2.71 mmHg; 95% CI −4.62 to −0.79 mmHg, P=0.006), diastolic blood pressure (−2.92 mmHg; 95% CI −4.47 to −1.37 mmHg, P＜0.001), and total cholesterol (−0.27 mmol/L; 95% CI −0.48 to −0.05 mmol/L, P=0.016). The intervention was also associated with significantly greater improvements in self-management behaviors, self-efficacy, and habit strength (all P<0.05).

Conclusions:

Digital structured education integrated with behavioral nudge tools improved metabolic outcomes and strengthened psychological and behavioral determinants of self-management among adults with type 2 diabetes over a 12-week period. By leveraging dual-process mechanisms and embedding environmental cues to support habit formation and self-efficacy, this nudge-enhanced digital approach extends beyond conventional reminder-based interventions and demonstrates promise for improving adherence and reinforcing short- to medium-term diabetes self-management. These findings highlight the potential value of incorporating behaviorally informed, home-based nudge strategies into scalable digital health programs. Longer-term and real-world studies are needed to assess the durability, generalizability, and sustained clinical impact of this approach. Clinical Trial: chictr.org.cn Identifier: ChiCTR2400082373 (Registered on March 27, 2024).