Diabetes mellitus is a serious chronic disorder that has a significant adverse effect on the overall health of families, individuals, and societies worldwide [1]. According to the International Diabetes Federation, the global prevalence of diabetes among adults aged 20-79 years was approximately 537 million in 2021 [2], representing 10.5% of the global adult population [2,3]. This number is projected to rise to 783.2 million (12.2%) in 2045 [3].

In the United States, DM is one of the most prevalent metabolic conditions, which impacts about 38.4 million of the overall US population (as of 2021), representing 11.6% of the total population. Of this number, 8.7 million are unaware and undiagnosed [4]. Moreover, 97.6 million US adults aged 18 years and older have prediabetes, which usually leads to diabetes [4]. In 2022, the total estimated costs, both direct and indirect, associated with diagnosed diabetes in the United States amounted to US $413 billion [4]. Type 2 diabetes (T2D) can lead to cardiovascular disease, blindness, peripheral neuropathy, and reduced quality of life [5] and is linked with significant morbidity rates [6]. DM is a health concern among all populations; however, persons with disabilities are more likely to be affected by diabetes compared to those without such disabilities [7-10].

Diabetes management primarily relies on individuals and their families, making self-management fundamental in diabetes care [11]. T2D management involves a range of actions and choices such as meal planning, scheduled physical activity, monitoring blood glucose levels, taking diabetes medications, and effectively managing episodes of illness and low and high blood sugar levels [11,12]. These behaviors are meant to regulate blood sugar levels, reduce the risk of complications, and improve the overall health of individuals with diabetes [13].

When individuals with diabetes actively participate in their own care, they can significantly impact both the progression and development of their disease [12]. However, a significant barrier to achieving proper glycemic control appears to be the patient’s inability to maintain adequate self-care, such as poor adherence to prescribed medications and lifestyle adjustments [14]. Thus, educating individuals to self-manage their diabetes yields better health results [15,16].

The literature highlights the potential for diabetes to cause disability; however, the reverse is also possible [17]. Living with disability is associated with an increased risk of DM. A study found that mild and incident disability was associated with 28% and 40% increased diabetes risk, respectively [18]. Diabetes is a significant health concern across all populations; however, persons with disabilities are more likely to be affected. The Centers for Disease Control and Prevention points out that in 2020, approximately 16.2% of persons with disabilities in the United States had received a diagnosis of diabetes, in contrast to 7.5% of those without disabilities [9]. Persons with disabilities are at a greater likelihood of experiencing the major risk factors associated with diabetes [19] due to challenges in maintaining a healthy diet and lifestyle as well as accessing preventive care [20,21].

Physical disability broadly includes conditions affecting mobility like spina bifida and muscular dystrophy [22]. People who are blind, deaf, missing limbs, partially or completely paralyzed, or have other permanent or chronic physical limitations are considered to have a physical disability [23]. Accessibility and safety are the primary concerns with physical disability, with common issues including accessing public areas like city streets, sidewalks, ramps, and public buildings [23]. Some of these disabilities require mobility devices like prostheses, orthoses, canes, wheelchairs, crutches, or walkers [23].

While effective diabetes management is significant in enhancing overall health, persons with disabilities often face barriers that hinder their diabetes self-management [24] and usually exhibit poorer self-management behaviors [24-29]. For instance, self-management behavior was found to be poor among individuals with diabetes and physical limitations [28]; they are less likely to engage in moderate to vigorous physical activity or adhere to their medication compared to those without physical limitations [28]. Individuals with mobility difficulties may encounter challenges attending health care provider appointments related to their diabetes [28]. A study discovered that about 11% of adults with mobility disability had not visited a health professional for their diabetes within the past year [25]. Persons living with physical disabilities in general encounter several difficulties in maintaining a healthy diet [27]. A study found that factors including knowledge, fatigue, health condition, and function impairments influenced the dietary behavior of wheelchair users [27]. Similarly, Hall et al [30] discovered that the expense of healthy foods, a lack of motivation, shopping challenges, and time constraints for shopping or food preparation are significant barriers to maintaining a healthy diet among women with physical disabilities. Nonetheless, the authors noted that about 90% of participants were interested in improving their dietary habits [30]. Another study examining the nutritional status of individuals with spinal cord injury revealed significant deficiencies in essential nutrients, notably fiber, calcium, fruits, and dairy products [31].

Moreover, the participation of persons with disabilities in self-management interventions is limited [24], and their specific self-management needs and capabilities are unrecognized by health care professionals [24,25,29]. It was discovered that 47% of adults with disabilities have not received education on managing diabetes [25]. Age, gender, lack of accessibility, and low socioeconomic status have been found to impact diabetes self-care behaviors among persons with disabilities [24]. In addition, for individuals who are visually impaired, factors such as poor health, concerns about disease advancement, feelings of grief, and experiences of loss inhibit their engagement in diabetes self-care behaviors [29]. Taken together, these barriers can make self-management more challenging particularly for individuals with a physical disability and T2D.

A systematic review of factors influencing the adoption of diabetes management technologies identified monthly income, gender, age, educational level, and diabetes-related characteristics as key determinants of their use; however, of all 28 studies included in the review, disability status was not considered as a factor that could influence technology use in diabetes management [32]. There is limited technology-based diabetes self-management tailored specifically for persons with disabilities [33].

Recently, digital health technologies have progressively been integrated into diabetes education, functioning as either an adjunct to or a substitute for traditional in-person methods [34]. Using technology in diabetes education reduces care inequities, increases the efficacy of educational initiatives, and improves accessibility. Technology as a means of diabetes education is supported by the broad use of telehealth and digital platforms by both patients and health care professionals [35]. Patients and health care professionals have accepted the use of telemedicine and other digital tools to educate people about diabetes. The COVID-19 pandemic has, in fact, significantly increased interest in and demand for telehealth-based diabetes education. The emergence and progress of digital health technologies have resulted in several modalities for engaging and educating patients through telephone or smartphone, video or audio, web, SMS text messaging, and mobile apps, as well as combinations of these methods [35].

In this study, participants are randomized into 3 intervention groups: an attention control group, a low-technology group, and a high-technology group. The purpose of this design is to evaluate the effectiveness of varying levels of technological integration in delivering medical nutrition therapy (MNT) and diabetes self-management education (DSME). All groups receive the same frequency and quality of remote education sessions. Both the low-technology and high-technology groups receive bidirectional SMS text messaging to facilitate timely communication with a health coach. In contrast, the attention control group does not receive any text-based communication or access to a health coach. Additionally, the high-technology group receives weekly diabetes-related educational materials via multiple channels (email and text), regular text reminders (eg, to read content, track health data, and stay motivated), and access to a telehealth platform. The low-technology group receives only 1 weekly email with diabetes-related educational materials. The attention control group does not receive any supplementary educational content or access to technology-based support resources.

The aim of this study is to implement and evaluate the impact of different levels of technology on the delivery of MNT and DSME among persons with mobility disability and T2D. We hypothesize that participants in the high-technology group will have improved self-management behaviors and better glycated hemoglobin (HbA_1c) reduction compared to their counterparts in the low-technology and the attention control groups.

We hypothesize that participants in the high- or low-technology intervention groups will show improvements in self-management behaviors related to T2D and self-efficacy compared to the control group at the 6-month follow-up. Again, we hypothesize that the high-technology intervention arm will result in better outcomes regarding reductions in HbA_1c than the low-technology and control arms. Additionally, we also hypothesize that the YumABLE intervention is feasible and acceptable to adults with permanent physical disability and T2D and that fidelity to the program will be maintained.

The development of the telehealth platform, which includes the dashboard and educational content, along with the creation of the landing website, has been completed by the study’s technical support team. In addition, research personnel have developed the database using REDCap to serve as the storage for data and communication tools such as emails and text notifications. The study began in June 2024. Since June 2024, intervention materials have been finalized, the IRB submissions have been completed, and participant recruitment began. In total, 28 participants have been enrolled and received the MNT and DSME remote class. Recruitment has ended, and we anticipate completing data collection by August 2025. Make-up classes were delivered to participants in any of the 3 cohorts between November 2024 and December 2024. The final 3-month follow-up classes were held for each cohort 3 months after the first class and were completed in February 2025. Data will be analyzed in fall 2025. Manuscript preparation and dissemination of study results are planned for spring 2026.

Previous research has showed that comprehensive diabetes education is required to equip patients with the necessary self-management skills needed to manage the condition. Likewise, diabetes education has been found to improve patient knowledge, improve diabetes control, and delay complications [50-56]. The American Diabetes Association has pointed diabetes education as the cornerstone therapy for the patient with diabetes [54].

Numerous publications have highlighted the importance of technology in diabetes care and management [34,35,57]. Sharma et al [57] posit that technology use in providing diabetes education leads to improved patient access and clinical outcomes, reduces the cost of care, and addresses gaps in care. Patients with diabetes who get live telephone coaching for a specified duration can gain advantages from consistent health status monitoring, leading to enhanced self-efficacy, improved health outcomes, and decreased hospitalization rates, surgical expenses, and total health care expenditures [58-61]. The reduction of HbA_1c levels has been a notable benefit achieved by telephonic support [60].

Likewise, web-based education is an effective tool for promoting diabetes self-management. Some websites exclusively provide diabetes-related content and resources, while others include an opportunity to interact with a coach [62]. Other websites provide digital record-keeping tools that enable patients to track and monitor their food and physical activity as well as generate reports or logs [63]. Moreover, other websites include blogs, healthful recipes, menus, and holiday meal planning assistance [57]. Some clinical web-based supportive educational tools include remote chatting, discussion forums, emailing choices, and the ability to contact a live diabetes coach [57]. Indeed, web-based educational interventions have shown promise in supporting diabetes self-management. Such digital training approaches have been linked to enhanced treatment adherence and improved health indicators, highlighting their potential as effective tools in early diabetes care [63].

Given that self-management is crucial in managing T2D and also considering that persons with disabilities face barriers that prevent them from successfully managing their diabetes, a study looking to create an available, inclusive, and accessible diabetes management program for people with disabilities is important. To the best of our knowledge, there is no existing program in the United States explicitly providing remote DSME and MNT tailored for persons living with disabilities.

This study has limitations. Factors such as the supportive group setting, the instructor, or individual components of the program may influence health outcomes in different ways. To account for potential confounding factors, we have chosen a randomized design. Additionally, behavior changes, such as participating in an organized intervention, could contribute to improvements, including adopting healthier diets. As with any complex intervention, various factors may impact the outcomes. However, this reflects real-world clinical scenarios. Using a randomized design, the study aims to minimize the influence of confounding variables and provide more reliable findings. Additionally, several aspects of our trial design may pose potential limitations. First, participants with mobility limitations or accessibility issues may be unable to visit the contracted laboratory for their HbA_1c test and instead self-report their HbA_1c levels. These self-reported data may not be entirely accurate or up to date. Additionally, as the study is conducted remotely, some participants, particularly older individuals, may face technical challenges, such as difficulty navigating the platform or accessing the intervention materials.

That notwithstanding, this study has some strengths. To begin with, the methodological strengths of the study include the randomized controlled design, preregistration in a clinical trials registry, the inclusion of make-up and follow-up classes, and the use of both quantitative and qualitative measures. Another strength is a third-party testing company’s involvement in the HbA_1c tests, ensuring impartiality and reliability in the results.

The results from this study will expand our understanding of how technology-delivered behavioral interventions can effectively address the challenges of managing diabetes, particularly among individuals with permanent physical disabilities and their families. A combined approach of DSME and technology offers a promising, easily accessible, and engaging intervention that may serve as a practical pathway for improving diabetes management.

This study provides future directions. First, it can lead to more studies on how artificial intelligence could be used in the delivery of diabetes education among individuals with various forms of disabilities. In addition, the study can help provide insight regarding an effective approach to combine more than 1 technology in providing diabetes management education.

We intend to present study findings at diabetes, endocrinology, and digital health conferences and submit the data for publication in peer-reviewed open-access publications. In addition, we will consult with health care leaders and diabetes care teams within our health system on potential changes to diabetes education methods and digital intervention protocols.

In conclusion, this randomized controlled study, with an anticipated 90 participants, will explore the effects of combined DSME and technology among individuals with diabetes and a permanent physical disability. The primary aim is to assess how technology-enhanced DSME influences diabetes management. The findings from this intervention study could offer valuable insights for health care professionals, health educators, and public health personnel, informing future strategies for managing diabetes in individuals with physical disabilities and more broadly among all persons living with T2D.