A PES statement for Diabetes may not seem like your first choice for PES statements, but it actually should be used more often than you think.

We do tend to promote liberalized diets, and increasingly we’re seeing a decreased use of controlled carbohydrate diets. But that doesn’t mean that you can’t choose a PES statement for diabetes as a problem!

So if you’re going to select a PES statement for diabetes, let me help you pick the perfect statement!

How Does Diabetes Affect Diet?

If you’re a Dietitian (which most reading this post are) then you likely already know the answer to this question. But for those who are new to the profession, I’ll give a brief overview of what this looks like.

Diabetes is a chronic life long condition that someone has that involves the pancreas not being able to produce enough, or any insulin. This affects how the body processes sugar in the body, which in turn requires in most cases some nutrition interventions.

The nutrition interventions will vary based on a few things:

How tightly controlled the blood sugars are
The goal for A1C values
The quality of life the patient wants
Doctor’s blood sugar control goals
Family input
Age
Type 1 or Type 2 Diabetes

All of these factors are going to play into what the nutrition goals are for a patient with diabetes. Once you know the answer to these questions, it’s easier to formulate a PES statement.

Nutrition Goals for Diabetes

In my experience I have found that the older the patient with Diabetes, the less tightly controlled the blood sugar goals are. The risk of hypoglycemia and malnutrition are weighed heavily when choosing nutrition goals.

In most cases the nutrition goals for a patient with diabetes will be any of the following:

Maintain blood sugars within 7.6-9.0 mmol/L (137-162mg/dL)
Maintain A1c within 7.6%-8.5%
Monitor A1c every 3 months or as labs are available
Monitor blood sugars for regularity every 3 months or as available

As you can see, the ‘normal’ A1C and blood sugar levels are higher than in a normal, healthy, younger individual. These are levels that are generally used for frail, older adults with multiple comorbidities.

I can venture to say that most older adults, especially those in long term care, have multiple comorbidities, and border on frail. These values though do need to be agreed upon by the Doctor, as they will be the ones determining the acceptable normal range.

Nutrition Interventions for Diabetes

This too will be highly indvidiualised for each patient based on the nutrition goals that have been chosen. Hopefully your facility doesn’t put everyone with diabetes on a controlled carbohydrate diet. This is neither necessary nor person-centred care.

I am a big advocate of not only liberalizing diets, but also individualizing diets. If you want to know more about the advantages of liberalizing diets, check out this article.

Instead of putting a blanket controlled carbohydrate diet for everyone that has diabetes, you can instead choose some of the following nutrition interventions, in addition to the standard diet.

Replace regular juice with diet juice at meals and snack time
Replace regular sugar in coffee with an alternative sweetener
Continue with regular desserts instead of fruit cups
Offer higher protein options at dinner when pasta and potatoes are served
Offer high protein and high fibre snacks at afternoon and evening snack, in addition to the regular snack

All of these are focusing on managing blood sugars, while also maintaining a regular diet. This has the nutrition goal of:

Improving quality of life
Balancing blood sugars by increasing protein and fibre
Swapping out items that tend to raise the blood sugars high
Continuing with regular desserts for pleasure
Allowing the patient to choose their diet choices, while promoting balanced blood sugars

This is what person-centred care looks like.

PES Statement Guidelines

Here is the basics of PES statements, if you need more help with them check out the end of this article for some more links to articles!

P = The Nutrition Problem

This is going to be the issue that you are trying to resolve, only put a problem here that your nutrition interventions are going to address. 

For example if you’re putting ‘unintentional weight loss’, your interventions may be to increase calories. 

E = Etiology

This is what you think is causing the problem that you just chose. If you went through the how to treat and prevent weight loss blog, (click here if you missed it) you will have a pretty comprehensive understanding of how to perform a nutrition assessment.  

Your nutrition assessment will help you find out the etiology and will help guide your nutrition interventions.  Only give an etiology after you have done a full nutrition assessment, you can’t write this statement blind. 

You need your subjective and objective data to support your statement.

S/S = Signs & Symptoms

This is fairly self explanatory, but this is the evidence of your problem and root cause. The signs can be objective data that you discovered in your nutrition assessment.  

Ensure that your S/S are evidence to back up the rest of your statement. Also ensure that your nutrition intervention will try to reduce the signs and symptoms that you have measured/observed.

Your statement will always follow this format:

Problem related to Etiology as evidenced by Signs & Symptoms 

It’s standardised language and this includes the format that the statement is written in.

PES Statement for Diabetes: Examples

It may seem backwards to go to the PES statement for diabetes now, as this is one of the first steps in the nutrition care process. But I wanted to give you a little background on managing diabetes and the nutrition care process before stepping right into PES statements.

Here are the top 10 PES statements for Diabetes that can help you build ones for your patients!

1. Inadequate fibre intake related to insufficient consumption of high-fibre foods as evidenced by low daily dietary fibre intake, infrequent bowel movements and elevated blood sugars post meal.
   
2. Inconsistent carbohydrate intake related to decreased intake at meals as evidenced by episodes of hyper and hypoglycaemia, and intake records of <50% at meals.
   
3. Excessive carbohydrate intake related to frequent consumption of high-carbohydrate foods and beverages as evidenced by elevated postprandial blood glucose levels and A1C increase of 3% in 3/12.
   
4. Altered nutrition-related labs (A1C) related to poor glycemic control as evidenced by an elevated hemoglobin A1C level of 12.2%, indicating suboptimal diabetes management.
   
5. Inadequate fibre intake related to limited consumption of fruits, vegetables, and whole grains as evidenced by a daily dietary fibre intake below recommended levels and digestive irregularities.
   
6. Excessive carbohydrate intake related to frequent consumption of sugary snacks and beverages as evidenced by elevated postprandial blood glucose levels, patient request and A1C increase of 4.5% in 6/12.
   
7. Inconsistent carbohydrate intake related to erratic meal patterns and skipping meals related to Dementia as evidenced by fluctuating blood glucose levels and reported feelings of energy crashes.
   
8. Altered nutrition-related labs (A1C) related to uncontrolled diabetes secondary to stage 3 pressure injury as evidenced by an elevated hemoglobin A1C level of 11%.
   
9. Inadequate fibre intake related to a lack of inclusion of whole grains and legumes in the diet as evidenced by low daily fibre consumption and complaints of bloating.
   
10. Excessive carbohydrate intake related to regular consumption of large portions of refined grains and sugary foods as evidenced by elevated postprandial blood glucose levels and gradual weight gain of 7.5% in 3/12.
    

Diabetes Care Plan

The diabetes care plan will vary based on your patient’s specific nutrition goals, but here is a general one that you can use as a template.

Nutrition Diagnosis:

Altered nutrition-related labs (A1C) related to poor glycemic control as evidenced by an elevated hemoglobin A1C level of 12.2%, indicating suboptimal diabetes management.

Nutrition Goals:

Attain blood sugars within 7.6-9.0 mmol/L (137-162mg/dL) within 6 months.
Attain A1c within 7.6%-8.5% with 6 months.

Nutrition Interventions

Replace regular juice with diet juice at meals and snacks.
Ensure a serving of protein and high fibre snack at afternoon and evening snack.
Give double portions of protein at dinner.
Offer education to patient on blood sugar management.

Nutrition Monitoring and Evaluation:

Will reevaluate nutrition interventions and set nutrition goals within 6 months. RD has discussed all of the above and the patient is on board with the nutrition goals and interventions. Will reevaluate blood sugars monthly, and A1C at the 3 and 6 month mark via blood tests.

Dietitian Takeaway Points

• Managing diabetes in any area, but specifically in long term care requires a Dietitian to think more in terms of quality of life and diet liberalization.
  
• Preventing hypoglycemias and malnutrition should be considered highly important.
  
• Ensuring that the Dietitian, Doctor, patient and family are all on the same page in terms of diabetes management is also priority.
  
• Develop PES statements for diabetes with all of the above in mind.

Here are some other helpful PES statement articles for you!

Perfecting Your PES Statements: Free RD Guide.

Nutrition Diagnosis Examples: Masterclass for Dietitians.

Malnutrition PES Statements: Your Go-To Guide!