The prevalence of overweight and childhood obesity in Spain is one of the highest in Europe (26% and 12.2% respectively),1 along with Greece, Portugal, Italy, Malta, the United Kingdom and Ireland.2,3 According to the Spanish National Health Survey, the Autonomous City of Ceuta registers the highest prevalence of childhood obesity in Spain, with 24.7%, and the Autonomous Community of Aragon the lowest, with 2.7%, versus 10.6% in Madrid.4 Childhood obesity increases the risk of arterial hypertension, dyslipidaemia, diabetes and locomotor disorders, and of exacerbation of respiratory diseases such as asthma, and psychosocial disorders such as discrimination and low self-esteem.5

The causes of global childhood obesity are low physical activity, sedentarism and inappropriate diet, coupled with a high consumption of high-calorie, processed foods rich in sugars and saturated fats and poor in micronutrients, promoted by an unfavourable socio-economic environment.6,7 Spanish children consume processed products in excess, whereas the consumption of fruit, vegetables and legumes is inadequate.8,9 Furthermore, they have a deficit of fibre and complex carbohydrates and an excess of fats and sugars, accounting for 45.9% and 21.2% of total calorie intake respectively, far above the recommended values.10 Soft drinks, fruit juices and fruit drinks contribute from 5% to 6% total calorie intake of Spanish children and adolescents,11 corresponding to a mean consumption of around 200ml/day.12 Data from the Spanish National Health Survey shows that 17% of Spanish children aged 5 to 14 years consumed sugar-sweetened soft drinks daily in 2006, a figure that fell to 11% in 2011, after the 2008 economic crisis13. When looking at those children in the same age range belonging to the low socio-economic class, the figures for daily consumption of sugar-sweetened soft drinks where over 30% in 2006 and 17% in 2011.

Childhood is a crucial period for preventing overweight and obesity, since it is then that dietary habits are formed which will endure into adult ages. Hence, the special emphasis laid on the childhood population by the Strategy for Nutrition, Physical Activity and Prevention of Obesity (Estrategia para la Nutrición, Actividad Física, Prevención de la Obesidad y Salud/NAOS) and the choice of a school setting as a one of the priority areas for intervention.14 One of the first initiatives was the 2005 Collaboration Agreement 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, and improving the nutritional quality of the items on offer, including those that would contribute to a balanced diet at the expense of others with a high salt, sugar or fat content. In 2008, a study of Madrid primary schools reported negligible compliance with the agreement.15 In 2010, the National Health System Interterritorial Council (NHSIC) approved the Consensus Document on School Food (Documento de Consenso del Sistema Nacional de Salud sobre Alimentación en los Centros Educativos),16 which laid down school-canteen food guidelines and the nutritional criteria to be met by food and drinks offered in school cafeteria and vending machines.

Many studies have assessed adherence to the schools’ meals recommendations by school canteens,17–20 but in a literature review we found no previous research focused on the products sold in food and drink vending machines in Spain. Accordingly, this study describes the nutritional content of products found in vending machines at secondary schools (Centros de Educación Secundaria) in the Madrid Autonomous Community, and evaluates their adherence to the Consensus Document on School Food recommendations.

The nutritional content of the 55 food and drink products is shown in Table 2. The average portion size was 56.4g for foods and 267.2ml for drinks. Every portion of product provided a mean of 186.1kcal; of this, 31.1% came from sugars, 5.1% from proteins, 39% from total fats, and 14.8% from saturated fats. A comparison between these figures and the nutritional goals of the Spanish Society for Community Nutrition (Sociedad Española de Nutrición Comunitaria)27 and the WHO sugar guidelines,25 led to the conclusion that the products sold in the machines had an excessive sugar and fat (total and saturated) content and were low in complex carbohydrates.

Most products (67.3%) were foods. Table 3 shows that 94.5% of products failed to comply with at least one of the Consensus Document on School Food nutritional criteria, with this percentage being lower for drinks than for foods (88.8% versus 97.8%; p=0.25). The two milk drinks were in breach of the Consensus Document (Bifrutas Tropical Pineapple and Pascual Chocolate Milkshake); and of the remaining drinks, only two (water and Aquarius Lemon) complied with all the nutritional criteria. Regarding foods, only a mixed sandwich met all the Consensus Document nutritional criteria.

The criterion which registered the highest rate of non-adherence was that governing sugar, with more than a half of all food and drink products being non-compliant (Figure 2). When the stricter WHO guideline criterion was applied (<10% of total caloric intake from sugar), more than two thirds (69.1%) of the products were non-compliant. A total of 47.3% of products supplied more energy than recommended, and 45.5% of them failed to comply with the criteria governing total fat. The best performance was observed for the criteria of the salt/sodium and trans-fatty acids with non-compliance rates below 25%.

Figure 2.

Percentage of non-adherence to the Consensus Document on School Food nutritional criteria in food and drinks products offered in vending machines at secondary schools in the Madrid Autonomous Community, 2014-2015.

(0.15MB).

Whereas the rate of non-adherence with nutritional criteria for foods ranged from 2.7% for artificial sweeteners to 70.3% for energy, drinks were only non-compliant in the case of sugars and artificial sweeteners, with rates of 38.9% and 61.1% respectively (Table 4). According to the WHO sugar guideline, non-compliance in foods was 73% versus 61.1% in drinks, though this difference did not prove statistically significant. Differences between food and drinks in terms of non-compliance with the Consensus Document criteria were statistically significant, except in the case of trans-fatty acids and sugar.

A total of 40% of products failed to comply with only one of the Consensus Document nutritional criteria, whereas 27.2% breached four or five criteria out of a total of seven. The mean number of unmet criteria was 2.2 (95% confidence interval: 1.85-2.62), with this figure being higher in foods than in drinks (2.8 versus 1; p <0.01).

This study shows that the products sold in secondary schools vending machines in the Madrid Autonomous Community have a high energy content, with sugars and fats being responsible for the highest caloric contribution. A total of 94.5% of products were in breach of at least one of the Consensus Document on School Food nutritional criteria, with a mean of more than two unmet criteria per product. The criterion registering the highest non-compliance rate was that of sugar (52.7% of products), followed by energy (47.3%) and fats (45.5%). The proportion of non-compliance was greater in foods than in drinks, both overall and for all the criteria analysed, with the single exception of artificial sweeteners.

A similar study covering Madrid Autonomous Community primary schools in 2008 showed that only 10% of vending machine products complied with the recommendations of the then prevailing agreement between the government authorities and Spanish National Association of Automatic Vending Distributors,15 as compared to 5.5% of those that met all the Consensus Document on School Food criteria in this study. Although the figures are not directly comparable, in that they are based on different criteria, both studies reveal the high prevalence of energy-dense, nutrient-poor foods in vending machines at Madrid schools. In a previous analysis of the data from this study using the United Kingdom Nutrient Profiling Model,28 as few as 19.5% of products were classified as healthy. This is mainly due to the fact that the UK nutritional profile permits a product containing artificial sweeteners to be as healthy, provided that the remaining ingredients conform to the model.21 Another Madrid primary-school study in 2009, which also analysed the range of items offered by school cafeterias, found that this was dominated by soft drinks, bottled, canned and packaged juices, and industrial cakes and pastries.29 Similar results were reported at an international level,30–32 where vending machines mostly contain energy products, rich in fat, sugar and salt, and poor in micronutrients and fibre.

The criterion to display the lowest adherence was that governing sugar, in that over half the products exceeded the established limit. In terms of WHO guidelines, non-compliance was 69.1%. This is due to the fact that, whereas the WHO recommends limiting consumption of free sugars to 10% of total calorie intake,25 the Consensus Document on School Food permits three times more, arguing that most of the products on the market have a high sugar content and that application of the WHO criterion would lead to vending machines being left unstocked. However, the Consensus Document on School Food itself saw such flexibility as being temporary, setting a provisional limit of 30% that would spur producers to reduce the sugar in food and drinks.16 Yet, five years after its publication, sugar content continues to be excessive, even by reference to lenient criteria such as those of the Consensus Document on School Food, and the practical totality of the food and drinks on offer are in breach of one or more of its criteria. The industry has not advanced in terms of reformulating its products to improve their nutritional profile.

The ready availability in vending machines of products with a high energy content, rich in sugar, salt or fat, and poor in micronutrients, is associated with a higher consumption of these products and greater risk of obesity.33,34 Strategies for positive reinforcement of water consumption through teacher appraisals coupled with reduced access to sugary drinks, and reduced barriers to obtain healthy water, have led to greater water consumption in US and Mexican students.35 Other strategies such as replacement of these products with others lower in calories, or the installation of water fountains in schools are effective for promoting healthier choices by pupils and preventing obesity.36–38 In fact, substituting water for sugary drinks reduces the energy intake by as much as 235kcal/day in children of all ages.39,40 This evidence shows the importance of the school food environment in the prevention of childhood obesity and the need to implement rules that ensure the availability of water fountains and a healthy range of products on offer in vending machines and school cafeterias.41,42 One example of these types of policies in Spain are the Draft Bill on the Promotion of an Active Life and Balanced Diet in Andalusia (Anteproyecto de Ley para la promoción de una vida activa y una alimentación equilibrada en Andalucía), currently under open consultation by the Andalusian Regional Authority, which will guarantee free access to drinking water in schools, public places and children's sports and recreation centres.43 A step further, the Autonomous Community of Murcia has forbidden the sale of energy dense foods and drinks (rich in sugars or fat and poor in nutrients) at schools.44

In the European Union, school food policies vary widely among countries. Whilst in France and Denmark vending machines are banned at schools, Austria, Portugal and Scotland prohibit the marketing of unhealthy products, and a third group of countries only issue recommendations about products to be offered in vending machines.45 This latter group includes Spain, which has issued a series of recommendations that the Autonomous Communities may or may not implement. Added to this is the fact that little is known about the Consensus Document in schools17 and that there is a lack of qualified staff to assess the type of products being sold in the machines: indeed, the Consensus Document on School Food stipulates that the persons or companies responsible for supplying and servicing the vending machines are also to be responsible for checking that the products comply with the guideline criteria,16 thus leaving this decision in the hands of third parties with conflicts of interest.

Hence, it is necessary to draw up stricter nutritional criteria, and disseminate them among food producers, venders, parents, teachers and school staff in charge of procurement and supervision of the food supply at schools, as well as to establish a system that ensures compliance with the Consensus Document recommendations. In view of the failure of a system based exclusively on voluntary recommendations, in order to prompt manufacturers to reduce sugar and offer healthier products, we feel that the new nutritional criteria should not only be in line with those of the WHO, but should also be compulsory. The experiences of the United Kingdom and France show that these measures are very effective when there are sufficient resources for their implementation and follow-up;46,47 also the experience of Mexico shows how the effectiveness can be compromised when there is a lack of resources and effective accountability and monitoring mechanisms to implement and assess nutrition policies.48 Currently, the school community in Madrid is not fully aware of the Consensus Document on School Food and lacks a formal system for monitoring and evaluating the nutritional quality of the products offered in vending machines. This situation can only improve with adequate resources, which ultimately rely on the political will of the national and regional authorities. Some Autonomous Communities, like Andalucía and Islas Baleares, are planning to make the nutritional criteria of the Consensus Document compulsory, and to set systems to assess its implementation.43,49

While the high percentage of non-response on the part of the secondary schools is a limitation of this study, the characteristics of the schools that agreed and those that refused to participate in the study were nonetheless similar.21 Furthermore, though the Consensus Document on School Food recommendations are applicable nationwide, the scope of the study was limited to the Madrid Autonomous Community, so the results might not be extrapolated to the rest of the country. The main strength of this study was that it is the first in Spain to evaluate adherence to the Consensus Document on School Food recommendations in secondary schools vending machines. Accordingly, it could serve as a reference for analysing the trend in the nutritional quality of such products and their degree of adherence to this Document in Madrid.

In conclusion, the practical totality of food and drinks on offer in vending machines at Madrid secondary schools are in breach of the Consensus Document on School Food recommendations, mainly due to an excess of calories, sugars and fats. The high sugar content of most of the products is particularly worrying, and we suggest that the maximum permitted should be reduced to 10% of their total calorie content, as recommended by the WHO. Moreover, the Consensus Document nutritional criteria should be made compulsory, and an appropriate follow-up system should be set up. This recommendation has been recently embraced by the Spanish Alliance for a Healthy Diet, a group of non-government organizations, including public health associations, aimed to promote food policies for the prevention of obesity and non-transmissible diseases related with unhealthy food habits.50

Laura I. González Zapata.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

M.A. Royo-Bordonada designed the study. M.L. Jácome-González and M.A. Moya-Geromini participated in data-collection, -processing and -analysis. D.X. Monroy-Parada wrote the first draft of the paper with the help of M.L. Jácome-González and M.A. Royo-Bordonada; and F. Rodríguez-Artalejo made important contributions. All authors contributed to the revision and approval of the final manuscript.

This project has been partially supported by the Spanish Health Research Fund of the Institute of Health Carlos III (Project ENPY 1015/13) and Asociación Madrileña de Salud Pública.

None.