When comparing beverage products from vending machines in different health and social care institution (hospital, community health centre, nursing home), the results do not significantly differ between the various institutions. We can estimate that the availability of beverages, as well as the nutritional quality of the beverages, is quite similar. In this study we found that 56% of all beverage front-face items available from vending machines is of lower nutritional quality. This proportion is slightly higher when compared to the beverages available in the Slovenian food supply, where 50% as was shown in a previous study (22). A recent international comparison (23) showed considerable potential for improving nutritional quality for beverages. Slovenia was in the bottom third with lower nutritional quality for beverages, and average sugar content of 7.5 g and 170 kJ per 100 ml (23). The average sugar content and average calories in beverages sold in vending machine are slightly lower when compared with an average sugar content of 6.7 g and 120 kJ per 100 ml in beverages sold in food stores. Beverages with no sugar and with non-sugar sweeteners are evaluated as healthier by FSANZ, however this is in contradiction with the WHO nutrient profile model (26), which does not support the addition of non-sugar sweeteners to beverages. The most notable problem in displayed beverages is a very high free sugar content. This is not in line with the scientific opinions of several eminent professional associations that claim that children, adolescents and adults should drink water or unsweetened tea instead of sugar sweetened beverages and natural juices (8–11). WHO guidelines recommend adults and children to reduce their daily intake of free sugars to less than 10% (roughly 50 g) of total energy intake, while the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and British recommendations (SACN) recommend less than 5% of total energy intake (3.5-9 g/day for children and adolescents aged 2–18 years). Compared to the results of our survey, the recommended daily intake of free sugars is nearly used when consuming only one average 500 ml carbonated beverage with free sugar. Although 100% natural juices seem like a healthy option, free sugar is naturally occurring and in liquid form (not added sugar) in those products, which, in addition to high intake, also affect the risk of developing obesity and non-communicable diseases (10). When choosing one average sugar-sweetened beverage form a vending machine, containing approximately 140 kcal, the five to seven percent of recommend daily calorie intake for an adult person and up to 12% of recommend daily calorie intake for small children (27) is already used.
Considering the increasingly popular vending machines and the trend of eating out (28–32), vending machines can be considered as an important environmental factor contributing to the obesity epidemic. Our results comply with the findings of other studies that snacks and drinks at vending machines located in various settings have limited healthy choices and high-energy and low nutrient snacks are the first-choice options (1, 3, 4, 33–35). In this context, vending machines represent a potential point of intervention for changing buyers' eating habits to healthier choices (3). Foods and beverages sold in vending machines are increasingly being scrutinized and addressed by federal policies. As a result, calls for local authorities to develop programs to promote healthier vending machines have been made overseas (36–41). The Slovenian School Nutrition Law (42) has prohibited vending machines in Slovenian primary and secondary schools since 2012. However, placing vending machines, as well as the nutritional values of available products in social and healthcare institutions, are not regulated by law. Thus, even those consumers who are aware of a healthy diet at the moment of choosing, do not have the option of a healthy choice (35). Healthier vending machine programs have already been implemented abroad in various settings such as hospitals (43); city parks (44); public buildings, government offices (45) and schools and university campuses (46–50). Strategies that have already been used overseas mainly include enhancing healthier products on offer (43, 51–53) and changing prices and promoting healthier choices with posters, brands, and stickers (3, 4, 54–57).
Another concern that should be highlighted is that the majority of beverages are displayed in plastic packaging, which contributes to the high carbon footprint of bottled water (58, 59). Bottled water in Slovenia is also incomparably expensive compared with tap water (60). Used once, the plastic packaging ends up at the waste collection centre (or even in nature), where in Slovenia, only 26% of plastics are recycled, mostly in downgrading processes (60, 61). Approximately 36% of plastic packaging is re-used for energy by incineration (61), where toxic by-products, such as dioxins, are produced. Dioxins are toxic substances that show harmful effects on the skin and the immune system, are reproductive toxic and teratogenic, interfere with hormonal balance and are carcinogenic (62). Plastics will, under environmental impacts, slowly degrade into micro plastics, for which bioaccumulation and bio magnification processes through the food chain can cause concern for human health (63, 64). As selling beverages in vending machines requires packaging, the disadvantages of plastics could be addressed by introducing alternative materials for packaging, such as bioplastics (65), glass, metals or paper and paperboard (66, 67).