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Aqua WOW: Creating Healthy Choices at Medication Pass Times
Many long-term care (LTC) facilities have traditionally dispensed juices to patients with their medications and offered juice as a snack between meals, as a drink with meals, and to provide hydration. Juices, particularly those containing high quantities of sugar or corn syrup, are increasingly coming under fire, however, for their potential negative effects on health. Juices have been criticized because they supply calories without inducing satiety or compensation (taking in fewer calories later in the day to compensate for juice consumption), are low in fiber, and high in sugars.1,2
The practice at Edgemoor DPSNF Hospital in Santee, California, was to administer all oral patient medications with 100% fruit juice. The dietary department delivered the fruit juice to the nursing unit every other day, where it was stored in refrigerators in cartons or in individual containers. Nurses were required to monitor the stored juices regularly to ensure that they were used or discarded prior to their expiration date, especially opened containers of juice left over from a medication pass. When patients did not finish their juice at medication pass, the disposable juice cup was discarded in the room’s trash can, where it served as a lure for ants, which were a problem in our facility.
Medication pass occurs 3 to 4 times daily for each patient at Edgemoor, and historically, at least one fresh, 4-oz cup of prepackaged apple juice has been provided on each occasion to aid the patient with swallowing oral medications. Depending on the type of juice used, each 4-oz cup contained an estimated 80 to 100 calories, adding approximately 300 to 400 calories3 daily to every patient’s dietary intake.
While it is not uncommon for patients in LTC to suffer from low appetite and weight loss, the proportion of LTC residents considered overweight or obese is growing.4 The median age of patients at Edgemoor is 55 years, which is lower than the average age of LTC patients nationwide, and patients at our facility are more likely to be overweight than underweight. Nursing staff at Edgemoor were concerned about providing these patients with hundreds of relatively empty calories each day. In addition, although oral care is performed after every meal at Edgemoor, it is not conducted after medication pass, and another concern was that sugar from fruit juices consumed between meals remained in the patient’s mouth and accumulated plaque. These and other health concerns, as well as the desire to save time and expense, contributed to the institution’s decision to investigate substituting zero-calorie flavored water for fruit juice at medication pass times.
Methodology and Results
In October 2009, Edgemoor decided to substitute zero-calorie flavored water in lieu of juice at medication pass on all six nursing stations (Table). The calorie-free flavored water we selected contains, in addition to water, natural flavors, citric acid, sodium hexametaphosphate, phosphoric acid, sodium benzoate, sodium citrate, and sucralose.4 Sucralose is a sweetener made from a combination of sucrose (ie, table sugar) and chlorine. Estimated to be 600 times sweeter than sugar, sucralose is used in much smaller quantities. The body does not absorb sucralose and thus it supplies no calories.5 Although sucralose may be “sticky,” because significantly smaller quantities than sugar are needed to achieve a similar level of sweetness, the stickiness of sucralose is likely negligible.
Three flavors of water—lemon-lime, strawberry-kiwi, and mango—from SUNKIST-Aqua Cal were made available via an automatic dispenser housed in the nursing unit nutrition room. At the press of a button, the water mixes with the flavoring in the dispenser, and the freshly made flavored water flows into a cup or pitcher placed near the dispenser. Any unused flavored water is poured down the drain, minimizing waste and the likelihood of attracting ants.
Measuring Effects on Weight
To evaluate the effects on patients of changing from fruit juice to water during medication pass, staff reviewed weight records for a cohort of 67 patients under care at Edgemoor from 2009 through 2010 whose medical status remained relatively consistent during this time. The cohort of 67 patients comprised 28 women and 39 men. The age of the women in the sample ranged from 39 to 83 years, with a mean age of 55.7 years. Men included in the cohort ranged from 27 to 71 years, with an average age of 51 years. Patient records from March 2009 to June 2009 were used to determine patient weights before the switch; post-change weights were obtained from August 2010 patient records.
In addition to documenting the patient’s weight, the records contain a monthly summary from the dietician that notes any significant changes in weight, defined as a weekly gain or loss ≥5 lb; a change in body weight ≥2% per week, ≥5% per month, ≥7.5% in 3 months, or ≥10% in 6 months; or any weight loss in an individual weighing <100 lb. We compared the total number of incidents of unexpected, undesired weight loss and weight gain from January 2009 to June 2009 with the total number of incidents recorded between January 2010 and June 2010.
Little overall change in weight was observed between the comparative periods. Prior to the intervention, the approximate cumulative weight of the patients was 11,406 lb; in August 2010, approximately 10 months after the introduction of flavored water, the patients’ cumulative weight was reduced to approximately 11,233 lb. In men, the mean change in weight was -3.79 lb, which was a 2% body weight loss difference (range of individual weight change, 19.37% body weight loss to 4.02% body weight gain). For women results showed weight changed a mean of <1 lb, which was <1% body weight loss (range of individual weight change, 8.16% body weight loss to 29.7% body weight gain). One patient had a weight gain of >15% from baseline, and one patient’s weight declined more than 15% from baseline. The health of these patients was relatively unchanged. Overall, 21 patients experienced a change in weight of <2% after implementation of the flavored water (Figure 1).
Cost Savings
The use of the flavored water was associated with significant cost reductions. Edgemoor received dispensers for the product at no cost in exchange for a commitment to purchase the liquid flavoring concentrate for 3 years. The concentrate costs $49.09 for a case of three containers, and it is estimated that over 3 years, Edgemoor will require 1260 cases. Each container costs $16.36 and provides 152, 4-oz servings of flavored water, at an estimated cost of $0.11 per serving. Assuming every patient receiving daily oral medication is given an average of 3.5 servings daily, the expense per person per day totals ~$0.385. In comparison, each juice cup costs ~$0.32, for an average daily cost per patient of $1.12. Thus, substituting flavored water for juice at medication pass reduces costs by ~$0.735 per patient per day (Figure 2).
The patient census for 2009 to 2010 shows Edgemoor had an average of 181 patients daily, of which 31 were receiving tube-only feedings. After excluding these 31 patients from the analysis, we calculated that it costs the facility $21,079 annually to provide flavored water for the remaining 150 patients at daily medication pass. This is less than one-third the amount Edgemoor spent on prepackaged juice cups for medication pass, which averaged $61,320 annually, and results in annual savings of $40,241 (Figure 3).
Patient and Staff Satisfaction
Interviews with 20 patients and 10 medication nurses subject to the change from fruit juice to flavored water found they were satisfied overall. Of the 20 patients interviewed, 92% said they preferred the flavored water over the juice when taking medications; 65% were unaware that the water had no calories. The finding of patient satisfaction was corroborated by the 10 medication nurses interviewed. According to 70% of the nurses, the patients enjoyed the flavored water when taking medication.
The nurses also reported receiving positive comments from patients about the choice of beverages “on tap” and that patients have been requesting the flavored water outside of medication pass times. The product provides hydration, gives patients an opportunity for decision-making, and stimulates the senses without supplying any additional calories. Some patients have commented that the water is easier to swallow than juice, and the nursing staff said they have observed less dental plaque among the patients since switching to the flavored water.
Additional Findings
The flavored water dispensers occupied more space in the medication rooms and required specialized cleaning procedures. This additional effort, however, was offset by time saved from no longer having to check for expired juice containers or manage space in the refrigerators, for example, to accommodate other patient snack products. Staff also had to learn to replace the empty containers of flavored concentrate with fresh containers. Less juice was needed, so less was delivered to the nursing unit and less was wasted. The frequency of dietary staff juice deliveries was greatly reduced, but medication pass times were not noticeably affected by the change.
Switching to flavored water contributed to a reduction in complex trash and helped Edgemoor “go green.” Instead of using cartons made of waxed cardboard that were lined with foil and contained a plastic spout, we converted to using reusable plastic pitchers. The flavored water product is also very clean and left no sugary residue on the paper cups that were used to distribute it. Spills are also no longer an issue, because the drink is essentially just water and thus has no residual stickiness. Using noncaloric, artificially sweetened drinks for all patients means nurses do not have to prepare separate drinks for diabetic versus nondiabetic patients. In addition, the reduction in cost of the product is significant, contributing to lowering overall nursing unit operating expense.
Discussion
In proposing a Beverage Guidance System for the United States, the Beverage Guidance Panel1 indicates water as the preferred beverage, followed in declining order by tea and coffee, low-fat milk, soy beverages, noncalorically sweetened beverages, beverages with some nutritional benefits (eg, fruit and vegetable juices, whole milk, and sports drinks), and calorically sweetened drinks lacking nutritional value. Compared with other noncaloric sweetened beverages, artificially sweetened flavored waters are relatively new to the beverage marketplace and are not specifically listed in the Beverage Guidance recommendations,6 but they appear to fall under the category of “noncalorically sweetened beverages.” The Beverage Guidance Panel notes emerging concerns that artificially sweetened beverages might condition individuals to prefer sweet foods and drinks, indicating that this is why they recommend them secondary to unsweetened drinks.1
The literature is conflicted as to whether it is beneficial or harmful to substitute calorie-free drinks prepared with artificial sweeteners for beverages sweetened with sucrose, high-fructose corn syrup, or natural sugars. Some studies have suggested that because artificial sweeteners alert the brain to sense sweetness but fail to supply the body with the energy expected, they create a disconnect that has effects on the metabolic system, such as triggering insulin release, which modifies dietary behavior and contributes to weight gain.7,8
A meta-analysis by Renwick and Molinary7 determined that many of the studies suggesting a causative link between artificial or “low-energy” sweeteners and appetite and weight gain were in vitro or involved mouse models. The authors stated that in vivo studies with human subjects provide no consistent support for the theory that artificial sweeteners contribute to increased appetite, weight gain, or insulin release. This is supported by a recently published randomized study that compared sucralose with water and maltodextrin (corn syrup solids) in healthy, normal-weight volunteers and found that sucralose had no effect on insulin or appetite.9
A literature review by Bellisle and Drewnowski8 looked at the effects of artificial or “intense” sweeteners on satiety and compensation. According to the researchers, variation between studies made it difficult to quantify the effects of the sweeteners. The authors did find, however, that randomized, controlled trials showed artificial sweeteners might contribute to modest weight loss. The authors concluded that a weight control strategy relying on artificially sweetened drinks is more likely to be effective than one that includes artificially sweetened foods.
The Beverage Guidance Panel advised caution when using noncaloric flavored water that is fortified with vitamins and minerals because these additives are not regulated.10 The panel noted that fortification might be appropriate in certain circumstances.
For average individuals, the Beverage Guidance Panel expressed agreement with the Institutes of Medicine that at least 60%—and as much as 100%—of fluid needs should be satisfied with calorie-free beverages and cited water as the preferred choice. This is especially important for individuals who have higher-than-average hydration needs.1
Conclusion
Our study indicates that using artificially sweetened flavored water at medication pass instead of fruit juice at an LTC facility offers several benefits, including improving efficiency and reducing costs and waste. Switching to the flavored water greatly reduced the task burden associated with using juice cups, reducing nursing unit involvement in ordering, receiving, and storing the juice.
Flavored water also helped reduce the daily caloric intake of patients at Edgemoor by an estimated 400 calories per day. Although it did not appear to have significant effects on weight, it is possible that it stemmed the rate of weight gain. Patients expressed appreciation for the choice of flavors, and its use has improved quality of life for patients and staff.
The authors report no relevant financial relationships.
Ms. Hilleary is a former administrator, Edgemoor DPSNF, Santee, CA, and adjunct professor of healthcare services, National University, San Diego, CA; and Dr. Ferrini is medical director, Edgemoor DPSNF Hospital, Santee, CA.
References
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4. Sahara Burst (orange/apple) [product label]. Houston, TX: Sysco Corporation; 2010.
5. US Department of Health and Human Services; Food and Drug Administration. Food additives permitted for direct addition to food for human consumption; sucralose. Final rule. 21 CFR §172. www.fda.gov/ohrms/dockets/98fr/081299b.txt. Effective August 12, 1999.
6. Beverage Guidance Panel. Beverage Intake in the United States. www.cpc.unc.edu/projects/beverage/panel_recommendations. Accessed June 25, 2011.
7. Renwick AG, Molinary SV. Sweet-taste receptors, low-energy sweeteners, glucose absorption and insulin release. Br J Nutr. 2010;104(10):1415-1420.
8. Bellisle F, Drewnowski A. Intense sweeteners, energy intake, and the control of body weight. Eur J Clin Nutr. 2007;61(6):691-700.
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10. Panel on Dietary Reference Intakes for Electrolytes and Water, Food and Nutrition Board, Institute of Medicine. 2004 Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: National Academy Press; 2004.
