Digital Structured Education With Behavioral Nudge Tools for Adults With Type 2 Diabetes: Multicenter Randomized Controlled Trial

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Abstract
Background: Digital interventions offer scalable alternatives to traditional face-to-face diabetes education, but often face challenges related to inconsistent clinical effectiveness, and declining user engagement. However, whether a digital structured education program integrated with behavioral nudge tools can improve metabolic, behavioral, and psychological outcomes in adults with type 2 diabetes remains unclear. Objective: This study aimed to evaluate the effectiveness of a digital structured education program integrated 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 4 hospitals in China. Adults with type 2 diabetes were randomly assigned to an intervention group receiving a digital structured education program integrated with behavioral nudge tools (n=146) or a control group receiving standard digital diabetes education (n=147). Assessments were conducted at baseline and 12-week follow-up. The primary outcome was hemoglobin A 1c (HbA 1c ) at 12 weeks, adjusted for baseline HbA 1c , and study center. Secondary outcomes included fasting blood glucose (FBG), weight, BMI, waist circumference, blood pressure, lipid profiles, self-management behaviors, self-efficacy, and habit strength. Results: Among 293 participants (mean age 49.19, SD 10.02 y), 287 (97.9%) completed follow-up. At 12 weeks, the intervention group demonstrated significantly greater improvements than the control group in HbA 1c (adjusted mean difference −0.38%, 95% CI −0.68% to −0.09%; P= .01), FBG (adjusted mean difference −0.75, 95% CI −1.27 to −0.44 mmol/L; P <.001), weight (adjusted mean difference −0.84, 95% CI −1.61 to −0.07 kg; P= .03), BMI (adjusted mean difference −0.38, 95% CI −0.65 to −0.11 kg/m²; P= .01), systolic blood pressure (adjusted mean difference −2.71, 95% CI −4.62 to −0.79 mm Hg; P= .01), diastolic blood pressure (adjusted mean difference −2.92, 95% CI −4.47 to −1.37 mm Hg; P <.001), and total cholesterol (adjusted mean difference −0.27, 95% CI −0.48 to −0.05 mmol/L; P= .02). The intervention was also associated with significantly greater improvements in self-management behaviors, self-efficacy, and habit strength (all P <.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. These findings suggest that a digital structured education program integrated with behavioral nudge tools may enhance diabetes self-management beyond standard digital diabetes education. Further studies with longer follow-up and real-world implementation are warranted to evaluate the sustainability, generalizability, and long-term clinical impact of this integrated intervention.

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