ABSTRACT

Background:

Policies restricting access to sugary drinks and unhealthy foods in the school environment are associated with healthier consumption patterns. In 2010, Spain approved a Consensus Document regarding Food at Schools with nutritional criteria to improve the nutritional profile of foods and drinks served at schools. The objective of this study was to describe the frequency of food and drink vending machines at secondary schools in Madrid, the products offered at them and their nutritional profile.

Methods:

Cross-sectional study of a random sample of 330 secondary schools in Madrid in 2014-2015. The characteristics of the schools and the existence of vending machines were recorded through the internet and by telephone interview. The products offered in a representative sample of 6 vending machines were identified by in situ inspection, and its nutritional composition was taken from its labeling. Finally, the nutritional profile of each product was analyzed with the United Kingdom profile model, which classifies products as healthy and less healthy.

Results:

The prevalence of vending machines was 17.3%. Among the products offered, 80.5% were less healthy food and drinks (high in energy, fat or sugar and poor in nutrients) and 10.5% were healthy products.

Conclusion:

Vending machines are common at secondary schools in Madrid. Most products at vending machines are less healthy.

Keywords:
Childhood obesity; Food vending machines; Secondary school. Dietary guidelines; Nutritive value; Diet; high-fat. Spain

INTRODUCTION

Childhood obesity is associated with a number of health problems, such as osteomuscular complaints, arterial hypertension, dyslipidaemia and type 2 diabetes mellitus, exacerbation of respiratory diseases including asthma, and psychosocial disorders, such as low self-esteem, discrimination and, among girls, depression.¹1. Davis S, Gomez Y, Lambert L, & Skipper B. Primary Prevention of Obesity in American Indian Childrena. Ann N Y Acad Sci.1993;699:167-80.^,22. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet. 2002;360:473-82. One third of children aged 2 to 15 years in Spain and one in four in the Madrid Region suffer from excess weight (overweight or obesity).³3. Agencia Española de Seguridad Alimentaria y Nutrición. Estudio de prevalencia de la obesidad infantil: Estudio Aladino (Alimentación, Actividad física, Desarrollo Infantil y Obesidad). Estrategia NAOS. Madrid: Agencia Española de Seguridad Alimentaria y Nutrición; 2011. Disponible en: http://www.aecosan.msssi.gob.es/AECOSAN/docs/documentos/nutricion/observatorio/estudio_ALADINO_2011.pdf
http://www.aecosan.msssi.gob.es/AECOSAN/... ^,44. Valdés-Pizarro J, Royo-Bordonada MA. Prevalence of childhood obesity in Spain: National Health Survey 2006-2007. Nutr Hosp. 2012;27:154-60. The 2013 Aladino (Alimentación, Actividad física, Desarrollo Infantil y Obesidad - Food, Physical activity, Child Development and Obesity) study, based on a representative population sample aged 7 and 8 years, reported that the prevalence of childhood obesity was stabilising and displaying a downward trend.⁵5. Agencia Española de Consumo, Seguridad Alimentaria y Nutrición. Estudio ALADINO 2013: Estudio de Vigilancia del Crecimiento, Alimentación, Actividad Física, Desarrollo Infantil y Obesidad en España 2013. Madrid: Agencia Española de Consumo, Seguridad Alimentaria y Nutrición; 2014. Disponible en: http://www.aecosan.msssi.gob.es/AECOSAN/docs/documentos/nutricion/observatorio/Estudio_ALADINO_2013.pdf
http://www.aecosan.msssi.gob.es/AECOSAN/... Excess weight among children and adolescents is partly due to an obesogenic environment which favours sedentarism, negligible physical activity and an unhealthy diet. The main risk factors of food-related childhood obesity are habitual consumption of sugary drinks, and high energy-dense diets due to excessive intake of processed foods rich in fats and added sugars.⁶6. Monasta L, Batty GD, Cattaneo A, Lutje V, Ronfani L, Van Lenthe FJ, Brug J. Early-life determinants of over-weight and obesity: a review of systematic reviews. Obes Rev. 2010;11:695-708.

7. Pérez-Escamilla R, Obbagy JE, Altman JM, et al. Dietary Energy Density and Body Weight in Adults and Children: A Systematic Review. J Acad Nutr Diet. 2012;112:671-84.^-88. Hebestreit A, Börnhorst C, Pala V, et al. Dietary energy density in young children across Europe. Int J Obes. 2014;38:124-34.

School plays a highly relevant role when it comes to developing dietary habits.⁹9. Dubois L, Farmer P, Girard M, Peterson K. Preschool children's eating behaviours are related to dietary adequacy and body weight. Eur J Clin Nutr. 2007;61:846-55.

10. Murray R, Bhatia J, Okamoto J, Allison M, Ancona R, Attisha et al. Snacks, sweetened beverages, added sugars, and schools. Pediatrics. 2015;135:575-83.^-1111. World Health Organization. Diet, nutrition and the prevention of chronic diseases: report of a Joint WHO/FAO Expert Consultation. WHO Technical Report Series. Geneva:World Health Organization; 2003. Disponible en: http://www.who.int/dietphysicalactivity/publications/trs916/en/
http://www.who.int/dietphysicalactivity/... In 2004, the World Health Organisation (WHO) implemented the Global Strategy on Diet, Physical Activity and Health, to reduce morbidity-mortality associated with these habits.¹²12. World Health Organization. Global Strategy on Diet, Physical Activity and Health. 57ª World Health Assembly. Geneva: Worl Healgh Organization; 2004. Disponible en: http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf
http://www.who.int/dietphysicalactivity/... In 2005, the Ministry of Health and Consumption drew up the Strategy for Nutrition, Physical Activity and Prevention of Obesity (Estrategia para la Nutrición, Actividad Física, Prevención de la Obesidad y Salud/NAOS) in Spain, with special emphasis on childhood.¹³13. Agencia Española de Seguridad Alimentaria. Estrategia para la nutrición, actividad física y prevención de la obesidad (NAOS). Invertir la tendencia de la obesidad. Madrid: Agencia Española de Seguridad Alimentaria; 2005. One of its initiatives in the school sphere was the agreement entered into with the Spanish National Association of Automatic Vending Distributors (Asociación Nacional Española de Distribuidores Automáticos) aimed at impeding the access of primary-school pupils to food and drink vending machines at educational centres and improving the nutritional quality of the items on offer. Nevertheless, a 2008 study at primary schools in Madrid reported widespread ignorance of and negligible compliance with the agreement.¹⁴14. Royo-Bordonada MA, Martinez-Huedo MA. Evaluation of compliance with the self-regulation agreement of the food and drink vending machine sector in primary schools in Madrid, Spain, in 2008. Gac Sanit. 2014;28:65-8. In this same year, the WHO issued a document to guide governments in the development of healthy school-dietary policies and facilitate implementation of its recommendations.¹⁵15. World Health Organization. School policy framework: implementation of the WHO Global Strategy on diet, physical activity and health. Geneva: World Health Organization; 2008. More recently, in its Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020 and in its European Food and Nutrition Action Plan 2015-2020, the WHO proposed various initiatives for fostering healthy dietary choices at school and limiting access to products high in fat, salt and/or sugar.¹⁶16. World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization; 2013.^,1717. World Health Organization Regional Office for Europe. European Food and Nutrition Action Plan 2015-2020. Copenhagen: World Health Organization; 2014. The European Union has moved in the same direction, by also promoting the consumption of tap water through the installation of water fountains at schools.¹⁸18. European Commission. EU Action plan on childhood obesity 2014-2020. EC; 2014. p. 1-68. Disponible en: http://ec.europa.eu/health/nutrition_physical_activity/docs/childhoodobesity_actionplan_2014_2020_en.pdf
http://ec.europa.eu/health/nutrition_phy...

In 2010, the National Health System Interterritorial Council (NHSIC) approved the Consensus Document on School Meals (CDSM) (Documento de Consenso sobre la Alimentación en los Centros Educativos) with nutritional criteria for school food and drink.¹⁹19. Consejo Interterritorial del Sistema Nacional de Salud. Documento de consenso sobre la alimentación en los centros educativos. Madrid: Consejo Interterritorial del Sistema Nacional de Salud; 2010. Disponible en:http://www.naos.aesan.msssi.gob.es/naos/ficheros/escolar/DOCUMENTO DE-CONSENSO PARA WEB.pdf
Disponible en:http://www.naos.aesan.msss... In 2011, the government passed the Food Safety & Nutrition Act (Ley de Seguridad Alimentaria y Nutrición):²⁰20. Boletín Oficial del Estado. Ley 17/2011, de 5 de julio, de Seguridad alimentaria y nutrición. 160, de 6 de julio de 2011. Article 40 of this Act prohibits the sale of food and drinks having a statutorily-defined high content of saturated fatty acids, trans-fatty acids, salt and sugar at nursery schools and schools. Although Spanish school menus are healthy²¹21. Berradre-Sáenz B, Royo-Bordonada MA, Bosqued MJ, Moya MA, López L. Menú escolar de los centros de enseñanza secundaria de Madrid: conocimiento y cumplimiento de las recomendaciones del Sistema Nacional de Salud. Gac Sanit. 2015;29:341-6. and eating at school is associated with a lower risk of childhood obesity,²²22. Ortega Anta RM, Lopez-Solaber AM, Perez-Farinos N. Associated factors of obesity in Spanish representative samples. Nutr Hosp. 2013;28 (Suppl 5):56-62. two recent studies in Madrid have nevertheless shown that, for the most part, food and drink vending machines offer energy-dense, nutrient-poor (EDNP) processed products. These studies do not, however, furnish detailed information on the nutritional profile of the products sold.¹⁴14. Royo-Bordonada MA, Martinez-Huedo MA. Evaluation of compliance with the self-regulation agreement of the food and drink vending machine sector in primary schools in Madrid, Spain, in 2008. Gac Sanit. 2014;28:65-8.^,2323. Confederación de Asociaciones de Consumidores y Usuarios de Madrid. Estudio sobre la oferta de bebidas y comida en máquinas expendedoras y cafeterías de los colegios de la Comunidad de Madrid. Madrid: Confederación de Asociaciones de Consumidores y Usuarios de Madrid; 2011. Disponible en: http://cecumadrid.org/web/images/stories/pdf/P_estudio_oferta_alimentacin_y_bebida_en_colegios_madrid_Parte1.pdf
http://cecumadrid.org/web/images/stories...

Accordingly, the aim of this study was to ascertain the frequency with which food and drink vending machines were to be found at secondary schools in Madrid during the 2014-2015 academic year, along with the range of products on display and their nutritional profile.

MATERIALS AND METHODS

We conducted a cross-sectional study whose target population were secondary schools (SS) (Institutos de Enseñanza Secundaria) in the Madrid Autonomous Region (MAR) during the 2013-2014 academic year. The list of schools was obtained from the MAR Internet School Portal.²⁴24. Comunidad de Madrid. Portal Escolar. Disponible en:http://www.madrid.org/wpad_pub/run/j/MostrarAdmision.icm
http://www.madrid.org/wpad_pub/run/j/Mos... In December 2013, a letter was sent to all SS describing this study and encouraging them to participate if selected. In January 2014, 511 SS were selected by simple random sampling and a senior staff member contacted by telephone to seek their participation. Where a school failed to reply, the telephone invitation was repeated and the school sent the e-mail questionnaire. The non-response rate was 35.4%, and the final sample comprised 330 SS. The main reasons for non-participation were lack of interest in the study or lack of time and availability.

Of the 330 SS, 57 (17.3%) had one or more vending machines, making a total of 93 such machines, with 23 (24.7%) selling food, 55 (59.2%) selling drink and 15 (16.1%) selling a mixed range of items. In view of the small variation in the products sold by machines in a previous study,(14) we included the lowest number of these that would make for a distribution similar to that of the original sample (food, drink and mixed). We thus obtained a subsample of 6 machines, made up of 1 with a mixed range (16.7%), due to this being the least frequent in the original sample, 2 with food (33.3%) and 3 with drink (50%). The machines were selected from 2 private, 2 public and 2 subsidised schools. Where the same product was available in more than one machine, we tallied as many as there were machines offering them, up to a maximum of 6 per product. As a result, the sample of products studied totalled 77.

Data were collected in two stages. In the first stage, from January to December 2014, we collected data on territorial area, school ownership (public, private, private subsidised), presence of a school canteen, and existence of other educational stages (nursery, primary or special), via the MAR Internet School Portal.²⁴24. Comunidad de Madrid. Portal Escolar. Disponible en:http://www.madrid.org/wpad_pub/run/j/MostrarAdmision.icm
http://www.madrid.org/wpad_pub/run/j/Mos... In addition, we used telephone interviews to obtain data on knowledge of the consensus document, number and type of vending machines, availability of cafeterias and water fountains, and existence of school food service supervisors and their professional qualifications.

In the second stage, from January to May 2015, visits were paid to SS to identify the 6 machines and photograph their products. Where the nutritional information of any item was not visible and was not available on the company's web page, a sample item was taken from the vending machine and the information obtained from the label. The CDSM lays down the following nutritional criteria for products sold in vending machines: a maximum energy value of 200 Kcal, a maximum of 35% of which may come from fat, 10% from saturated fats and 30% from sugars, as well as a maximum of 0.2 g of sodium; and no trans-fatty acids, artificial sweeteners, caffeine or other stimulants.

Products were classified into food items, which were, in turn, grouped into two categories as per earlier studies, namely: essentials (nutrient dense with a low-calorie content: cereals low in sugar and high in fibre (<20g sugar/100g and >5g dietary fibre/100g), vegetables and legumes, fruit, skimmed or semi-skimmed dairy products (milk and yoghurt with <3g fat/100g, and cheese with <15g fat/100g), lean meat and poultry, fish, eggs, tofu, nuts and seeds); and non-essentials (with a high salt, fat, added sugar and/or energy content).²⁵25. Kelly B, Halford JCG, Boyland EJ, Chapman K, Bautista-Castaño I, Berg C, et al. Television food advertising to children: A global perspective. Am J Public Health. 2010;100:1730-6. Furthermore, we analysed each product using the United Kingdom Nutrient Profiling Model, which was purpose-designed by experts to regulate food advertising targeted at children, by summarising the key nutritional dimensions (healthy and less healthy nutrients, and size of portion) and discriminating between products on the basis of their nutritional quality, and was therefore considered ideal for the purpose of this study.²⁶26. Adamson A, Spence S, Reed L, Conway R, Palmer A, Stewart E, et al. School food standards in the UK: implementation and evaluation. Public Health Nutr. 2013;16:968-81.

27. Lobstein T, Davies S. Defining and labelling "healthy" and "unhealthy" food. Public Health Nutr. 2009;12:331-40.^-2828. Department of Health. Nutrient Profiling Technical Guidance. London:Department of Health; 2011. Disponible en: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216094/dh_123492.pdf
https://www.gov.uk/government/uploads/sy... This model assesses healthy components (fibre, proteins, vegetables, fruit and nuts) and less healthy components (energy, sugars, saturated fats and salt) per 100g of edible product. The model obtains a final score using an algorithm that includes all the components. If the score is <4 for food or <1 for drinks, the product is then deemed to be "healthy". Where scores exceed these limits, however, the product is deemed to be "less healthy" (high saturated fat, sugar and salt content).

Statistical analysis. We calculated the frequency of SS which were equipped with vending machines, and then used the χ² test to compare these by reference to their characteristics (territorial area, educational stage, knowledge of the CDSM, and existence of cafeterias, water fountains, canteens, and school food service supervisors). Similarly, we calculated the frequency of products by item and category (essential/non-essential foods) and nutritional profile. All data analyses were performed using the Stata 12.0 software programme.²⁹29. StataCorp.2011 Stata Statistical Software: Release 12. College Station, TX: StataCorp LP.

RESULTS

Of the 330 SS that participated, 65.1% were located in metropolitan Madrid. In terms of ownership, educational stage and presence of school canteens, the percentages of the sample were similar to those of the target population, with 64% of the participating schools being privately owned (10.6% private and 53.4% subsidised private), 63% imparting primary and secondary education, and 62.1% having a canteen (table 1).

Table 2 shows that the percentage of schools with vending machines was higher among private (45.7%) than among public (16.8%) and subsidised schools (12%) (p<0.01). The presence of machines was also higher at schools with previous knowledge of the CDSM (23.4% vs 14.8%; p=0.06), water fountains (22.1% vs 12.7%; p=0.02) and school food service supervisors (47.1% vs. 11.5%; p<0.01); 41.2% of these supervisors lacked professional qualifications in nutrition (data not shown in table).

Table 3 describes the 77 products present in the 6 vending machines selected. In the category of essential products (10.5% of the total) water, milk and dairy products were the most frequent, accounting for 5.2% and 4% of the total respectively. In the non-essential category, the most frequent items were cakes and pastries (cakes, buns, biscuits, pies and pastries), with 27.2%, and sugary drinks with 23.3%. A total of 80.5% of all products were less healthy. Of the essential products, 2 were less healthy (25%), namely, 1 sandwich and 1 chocolate shake, which was one of the 3 low-fat dairy products. Of the non-essential products, 87% were less healthy, with this figure being lower for sugary drinks (55.6%) (table 3).

DISCUSSION

This study shows a considerable prevalence of vending machines at SS in Madrid, especially at private schools. Such machines were also more frequent in SS that were familiar with the CDSM, were equipped with water fountains and had school food service supervisors. The most frequent products on sale were cakes, buns and sugary drinks: of these, four in five were less healthy and only one in ten was essential.

The presence of vending machines was very similar to that of Catalonia in the period 2006-2012, with 18.3% of schools, though pupils were not permitted access to these machines at half of the schools.³⁰30. Agència de Salut Pública de Catalunya PReME - Programa de revisió de menús escolars. Memòria 2006-2012. Barcelona: Agència de Salut Pública de Catalunya; 2012. Disponible en: http://salutweb.gencat.cat/web/.content/home/ambits_tematics/per_perfils/centres_educatius/menus_escolars/programa_revisio_programacions_menus_escolars_catalunya_preme/documents/arxius/memo_preme_2012.pdf
http://salutweb.gencat.cat/web/.content/... In comparison with a similar study conducted in the city of Madrid in 2008,¹⁴14. Royo-Bordonada MA, Martinez-Huedo MA. Evaluation of compliance with the self-regulation agreement of the food and drink vending machine sector in primary schools in Madrid, Spain, in 2008. Gac Sanit. 2014;28:65-8. i.e, before the CDSM had been approved, the percentage of subsidised and private schools equipped with vending machines has almost doubled, rising from 10% in 2008 to 18% in 2014. Although the 2008 study was conducted on a representative primary-school sample, our data on subsidised and private schools are directly comparable because they all the schools involved impart two educational cycles. The differences might be due partly to the fact that our data are representative of schools in the Madrid Region as a whole, whereas those of the previous study correspond exclusively to the city of Madrid.

However, our study shows that the frequency of school vending machines in the city of Madrid and the rest of the region is almost identical. Furthermore, another study targeting all primary schools in the MAR in 2008-2009 also reported the absence of such machines at public schools and a very similar prevalence at private and subsidised schools.²³23. Confederación de Asociaciones de Consumidores y Usuarios de Madrid. Estudio sobre la oferta de bebidas y comida en máquinas expendedoras y cafeterías de los colegios de la Comunidad de Madrid. Madrid: Confederación de Asociaciones de Consumidores y Usuarios de Madrid; 2011. Disponible en: http://cecumadrid.org/web/images/stories/pdf/P_estudio_oferta_alimentacin_y_bebida_en_colegios_madrid_Parte1.pdf
http://cecumadrid.org/web/images/stories... Insofar as public SS were concerned, the percentage with machines fell sharply from 2008 to 2014, going from 32.3% in the city of Madrid³¹31. Martínez MA, Royo MA. Evaluación del cumplimiento del acuerdo entre los sectores sanitario y empresarial para la limitación del uso de las máquinas de distribución de alimentos y bebidas en los Colegios de Madrid. Comunicaciones orales y póster. XI Congreso Nacional de la Sociedad Española de Nutrición. Nutr Hosp. 2010;25:135. to 16.8% in our study.

The existence of the CDSM does not account for the differences in the presence of machines at public and private schools, since knowledge of this was very poor overall and slightly higher at subsidised and private schools (35.5%; data not shown in tables). This may possibly be due to the economic crisis, because from 2006 to 2012 the price of food and drinks increased by 12% in Spain,³²32. Instituto Nacional de Estadística. Productos y Servicios. El IPC en un clic. ¿Cuánto ha variado el IPC desde...? Cálculo de variaciones del Índice de Precios de Consumo. Madrid: INE; 2012. Disponible en: http://www.ine.es/varipc/
http://www.ine.es/varipc/... and 41% of Spaniards reported having changed their dietary habits in order to economise.³³33. Centro de Investigaciones Sociológicas. Barómetro de Diciembre. Avance de resultados. Estudio Nº 2.923. Madrid: Centro de Investigaciones Sociológicas; 2011. Disponible en: datos.cis.es/pdf/Es2923mar_A.pdf.
datos.cis.es/pdf/Es2923mar_A.pdf... This would appear to have led to a decrease in consumption of superfluous foods (e.g, refreshments and snacks), particularly among the lowest social classes,³⁴34. Encuesta Nacional de Salud de España. Disponible en:http://www.msssi.gob.es/estadEstudios/estadisticas/encuestaNacional/
http://www.msssi.gob.es/estadEstudios/es... thereby reducing the profit margin of machines at public schools.

Most of the products offered were rich in energy, high in fat, sugar and/or salt, and poor in micronutrients and fibre, in line with other studies in Spain¹⁴14. Royo-Bordonada MA, Martinez-Huedo MA. Evaluation of compliance with the self-regulation agreement of the food and drink vending machine sector in primary schools in Madrid, Spain, in 2008. Gac Sanit. 2014;28:65-8.^,2323. Confederación de Asociaciones de Consumidores y Usuarios de Madrid. Estudio sobre la oferta de bebidas y comida en máquinas expendedoras y cafeterías de los colegios de la Comunidad de Madrid. Madrid: Confederación de Asociaciones de Consumidores y Usuarios de Madrid; 2011. Disponible en: http://cecumadrid.org/web/images/stories/pdf/P_estudio_oferta_alimentacin_y_bebida_en_colegios_madrid_Parte1.pdf
http://cecumadrid.org/web/images/stories... ^,3131. Martínez MA, Royo MA. Evaluación del cumplimiento del acuerdo entre los sectores sanitario y empresarial para la limitación del uso de las máquinas de distribución de alimentos y bebidas en los Colegios de Madrid. Comunicaciones orales y póster. XI Congreso Nacional de la Sociedad Española de Nutrición. Nutr Hosp. 2010;25:135. and abroad.³⁵35. Byrd-Bredbenner C, Johnson M, Quick VM, Walsh J, Greene GW, Hoerr S, et al. Sweet and salty. An assessment of the snacks and beverages sold in vending machines on US post-secondary institution campuses. Appetite. 2012;58:1143-51.

36. Rovner AJ, Nansel TR, Wang J, Iannotti RJ. Food sold in school vending machines is associated with overall student dietary intake. J Adolesc Heal. 2011;48:13-9.^-3737. Lawrence S, Boyle M, Craypo L, Samuels S. The food and beverage vending environment in health care facilities participating in the healthy eating, active communities program. Pediatrics. 2009;123:287-92. Barely 10% of the items on sale were essential products.¹⁹19. Consejo Interterritorial del Sistema Nacional de Salud. Documento de consenso sobre la alimentación en los centros educativos. Madrid: Consejo Interterritorial del Sistema Nacional de Salud; 2010. Disponible en:http://www.naos.aesan.msssi.gob.es/naos/ficheros/escolar/DOCUMENTO DE-CONSENSO PARA WEB.pdf
Disponible en:http://www.naos.aesan.msss... Although the percentage of healthy products, according to the UK Nutrient Profiling Model, was double this figure, the differences were fundamentally due to the fact that refreshments with artificial sweeteners, discouraged by the CDSM, managed to obtain a healthy profile due to their low calorie content. Moreover, the consensus document displays a notable absence of many priority foods, such as fresh fruit, nuts, low-fat and low-salt cheese, and cereals and cereal products rich in fibre and low in fat, sugar and salt. This is surprising because half of the schools had school food service supervisors, though four in ten had no nutrition qualifications and only one in four knew of the existence of the CDSM.

In view of the fact that energy foods and sugary drinks in school vending machines are associated with a higher intake of these products³⁶36. Rovner AJ, Nansel TR, Wang J, Iannotti RJ. Food sold in school vending machines is associated with overall student dietary intake. J Adolesc Heal. 2011;48:13-9.^,3838. Bere E, Glomnes ES, te Velde SJ, Klepp KI. Determinants of adolescents' soft drink consumption. Public Heal Nutr. 2008;11:49-56. and that this, in turn, increases the risk of obesity,⁶6. Monasta L, Batty GD, Cattaneo A, Lutje V, Ronfani L, Van Lenthe FJ, Brug J. Early-life determinants of over-weight and obesity: a review of systematic reviews. Obes Rev. 2010;11:695-708.^,77. Pérez-Escamilla R, Obbagy JE, Altman JM, et al. Dietary Energy Density and Body Weight in Adults and Children: A Systematic Review. J Acad Nutr Diet. 2012;112:671-84.^,3939. Mâsse LC, de Niet-Fitzgerald JE, Watts AW, Naylor P-J, Saewyc EM. Associations between the school food environment, student consumption and body mass index of Canadian adolescents. Int J Behav Nutr Phys Act. 2014;11:29. the dominant presence of such products in the machines could contribute to the high prevalence of childhood obesity in the MAR4. Substituting water for sugary drinks reduces calorie intake among children and adolescents,⁴⁰40. Wang YC, Ludwig DS, Sonneville K, Gortmaker SL. Impact of change in sweetened caloric beverage consumption on energy intake among children and adolescents. Arch Pediatr Adolesc Med. 2009;163:336-43. so that replacing the machines with water fountains is an obesity-prevention strategy. A trial which consisted of installing water fountains at schools and undertaking a simple educational intervention designed to foster water consumption, succeeded in reducing overweight among pupils by one third.⁴¹41. Muckelbauer R, Libuda L, Clausen K. Promotion and Provision of Drinking Water in Schools for Overweight Prevention: Randomized. Pediatrics. 2009;123:661-7. Our data show that more than half of the SS are not equipped with water fountains, and that in 1 in 4 of all SS which do have water fountains, there are also machines stocked with sugary drinks. This means that there is still room for intervention in this field.

In the European Union, Norway and Switzerland, policies governing food and drink vending machines in schools range all the way from prohibiting such machines, as in France and Denmark, to banning unhealthy products or requiring a range of items in line with national dietary guidelines, through to simply recommending that healthy foods be prioritised.⁴²42. Storcksdieck genannt Bonsmann S. Comprehensive mapping of national school food policies across the European Union plus Norway and Switzerland. Nutr Bull. 2014;39:369-73.⁾ Along with Belgium and Italy, Spain is one of the least stringent countries, with the CDSM being limited to recommendations which Autonomous Regions may or may not apply. Furthermore, no formal follow-up and evaluation system is established. The Murcia Region has gone one step further by decreeing a ban on the sale of EDNP food and drinks at schools, whether in vending machines or in canteens, bars and shops.⁴³43. Boletín Oficial de la Región de Murcia. Decreto 97/2010 de 14 de mayo, por el que se establecen las características nutricionales de los menús y el fomento de hábitos alimentarios saludables en los Centros Docentes no Universitarios: BORM; núm 114 de 20 de mayo de 2010. Prohibiting the sale of sugary drinks and energy foods and/or requiring a range of healthy products is effective in promoting healthier consumption patterns.⁴4. Valdés-Pizarro J, Royo-Bordonada MA. Prevalence of childhood obesity in Spain: National Health Survey 2006-2007. Nutr Hosp. 2012;27:154-60. Even so, our study shows the inefficacy of a policy based solely on recommendations, without funding or a follow-up and evaluation system with clear goals and indicators. Indeed, the United Kingdom's experience with compulsory dietary standards in schools since September 2013 highlights the fact that the effectiveness of this measure requires adequate investment and an appropriate follow-up and evaluation mechanism.²⁶26. Adamson A, Spence S, Reed L, Conway R, Palmer A, Stewart E, et al. School food standards in the UK: implementation and evaluation. Public Health Nutr. 2013;16:968-81.

This study's principal limitation is the high percentage of non-response. However, there were no great differences between the characteristics of the schools that agreed and those that refused to participate. A further limitation lies in the fact that the results are only directly applicable to the MAR, which means that, though the recommendations analysed are of a national nature, the results cannot be directly extrapolated to the rest of the country.

In conclusion, the approval of the CDSM in 2010 has not succeeded in ensuring that products offered in school-based food and drink vending machines in the MAR have a good nutritional profile. The immense majority of these products are high in energy, rich in fats and/or sugar, and poor in micronutrients, in contravention of NHSIC guidelines. In view of the limited effectiveness of the NHS nutritional guidelines, compliance with these should thus be statutorily regulated, as envisaged by the Food Safety & Nutrition Act.

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