Aqua WOW: Creating Healthy Choices at Medication Pass Times: Page 2 of 2

July 22, 2011

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.


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



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.


1. Popkin BM, Armstrong LE, Bray GM, et al. A new proposed guidance system for beverage consumption in the United States [published correction appears in Am J Clin Nutr. 2007;86(2):525]. Am J Clin Nutr. 2006;83(3):529-542.

2. Dennis EA, Flack, KD, Davy BM. Beverage consumption and adult weight management: a review. Eat Behav. 2009;10(4):237-246.

3. Bradway C, DiResta J, Fleshner I, Polomano RC. Obesity in nursing homes: a critical review. Am Geriatr Soc. 2008;56(8):1528-1535.

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. Effective August 12, 1999.

6. Beverage Guidance Panel. Beverage Intake in the United States. 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.

9. Ford HE, Peters V, Martin M, et al. Effects of oral ingestion of sucralose on gut hormone response and appetite in healthy normal-weight subjects. Eur J Clin Nutr. 2011;65(4):508-513.

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.