HSE HEALTHIER VENDING POLICY Assessment of Compliance

Acknowledgements

The Healthy Eating Active Living Policy Priority Programme would like to thank the staff in the Health services for their help in gathering the information needed to compile this report, HSE Health Business Services and the companies on the National Vending Services framework.

Prepared by: Healthy Eating Active Living Policy Programme, Health Service Executive The data analyses for this report was undertaken by the National Nutrition Surveillance Centre (NNSC), School of Public Health, Physiotherapy and Sports Science, Woodview House, Belfield, University College Dublin, Dublin 4

S Bel-Serrat, I Stanley, CM Murrin, CC Kelleher.

This report should be cited as: Lawless A, Bel-Serrat S, Stanley I, O’Brien S, Murrin C, Kelleher CC [2018]. HSE Healthier Vending Policy. Assessment of Compliance, Dublin: Health Service Executive.

Foreword

The food we eat makes a significant contribution to our health and wellbeing. Research shows that excess consumption of foods high in fats, salt and sugar as well as low levels of vegetables and fruit intake increases our risk of developing chronic diseases such as heart disease, type 2 diabetes and cancer. The consumption of excess calories, particularly those with no nutritional value contributes to weight gain in children and adults.

The Irish Healthy Food for Life guidelines clarify that most confectionary foods, snacks and sugar sweetened beverages are high in fat, saIt and sugar, and as such should not form part of the daily diet.

We in the Health Services have identified promoting health and wellbeing in everything we do as one of our five corporate goals. In this context it is important that we take steps across our organisations to create environments that support our staff, patients and visitors to make healthier choices. The Healthier Vending Policy is an example of this, and I would like to acknowledge the work of all involved from across the HSE and our external contractors to implement the Policy since it came into effect in 2014.

The findings of this report provide us with a clear baseline from which to consider the role that vending services play in the provision of food in our sites and how this can be maximised to achieve our goal of promoting health and wellbeing in everything we do.

I would like thank, in particular, Agatha Lawless and Silvia Bel Serrat for their time and attention to detail in carrying out the assessment of compliance and finalising this report.

Sarah O’Brien

National Lead, Healthy Eating Active Living Programme

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Table of Contents

Acknowledgements ...... ii Foreword ...... iii List of Tables ...... vi List of Figures ...... vii Executive Summary ...... 1 Introduction ...... 4 Policy Context...... 5 Healthier Food Environment ...... 5 HSE Healthier Vending Policy ...... 6 Policy Implementation ...... 8 Monitoring of Healthier Vending Policy ...... 9 Methodology ...... 11 Data collection ...... 11 Product nutritional analyses ...... 11 60:40 analyses and product placement...... 12 Beverage Sales ...... 13 Results ...... 14 1.1 Product nutritional analyses: ‘Better Choice’ and ‘Other Choice’ products...... 14 1.1.1 Products stocked as ‘Better Choice’ products...... 14 1.1.2 Products stocked as ‘Other Choice’ Products...... 15 1.1.3 Identification of additional ‘Better Choice’ products...... 15 1.2 60:40 ratio analyses and product placement ...... 24 1.2.1 60:40 ratio analyses and product placement at company level ...... 24 Company 1 - 60:40 ratio analyses ...... 24 Company 1 - Product placement analyses ...... 26 Company 2 - 60:40 ratio analyses ...... 27 Company 2 - Product placement analyses ...... 27 1.2.2. Percentage of machines that met policy at site level ...... 30 1.3 Beverage sales ...... 38 Discussion ...... 53 Policy Implementation ...... 53 Compliance with the Policy ...... 53 Classification of products into Better Choice and Other Choice ...... 53

60:40 ratio of Better Choice and Other Choice products ...... 54 Product Placement ...... 54 Commission generated ...... 54 Beverage sales...... 54 Methodological limitations ...... 55 Conclusion ...... 56 Recommendations ...... 57 Appendices ...... 58 Appendix 1: Health service sites with vending machines ...... 58 Appendix 2: Scope of work for the National Nutrition Surveillance Centre (NNSC-UCD) to carry out to verify compliance with the Healthier Vending Policy...... 64 Appendix 3: Better Choice snack products that are available from UK and Irish market ...... 66 References ...... 67

List of Tables

Table 1 Breakdown of products stocked by companies as ‘Better Choice’ products that met/did not meet the Healthier Vending Policy ‘Better Choice’ classification in 2016. Table 2 Breakdown of products stocked by companies as ‘Other Choice’ products that met/did not meet the Healthier Vending Policy ‘Better Choice’ classification in 2016. Table 3 Products that meet the Healthier Vending Policy ‘Better Choice’ classification in 2016 including those stocked by the companies and those available in the market that were not stocked by the companies. Table 4 Products stocked by companies as ‘Better Choice’ products that meet the Healthier Vending Policy criteria (n=34). Table 5 Products stocked by companies as ‘Better Choice’ products that did not meet Healthier Vending Policy criteria, by number of criteria exceeded (n=18). Table 6 Food products stocked by companies as ‘Other Choice’ products in 2016 (n=51). Table 7 Beverages stocked by companies as ‘Other Choice’ products (2016) (n=14). Table 8 Number and proportion of ‘Better Choice’ and ‘Other Choice’ products stocked by Company 1, by vending machine type using company data. Table 9 Number and proportion of ‘Better Choice’ and ‘Other Choice’ products stocked by Company 2, by vending machine type. Table 10 Proportion of vending machines meeting the ratio 60:40 of ‘Better Choice’ and ‘Other Choice’ products at site and by Hospital Group/CHO and National/Corporate Services and Other services level based on nutritional information provided by the vending companies. Table 11 Beverage units sold at Hospital Group/CHO and National/Corporate and other Services level during 2016 by beverage category. Table 12 Better Choice beverage units sold at Hospital Group/CHO and National/Corporate and other Services level during 2016 by beverage category.

List of Figures

Figure 1 Placement of 'Better Choice' and 'Other Choice' products in Company 1 vending machines. Figure 2 Placement of 'Better Choice' and 'Other Choice' products in Company 2 snack machines. Figure 3 Placement of 'Better Choice' and 'Other Choice' products in Company 2 drink machines.

Figure 4 Placement of 'Better Choice' and 'Other Choice' products in Company 2 combination machines. Figure 5 Proportion of vending machines (n=295) meeting the ratio 60:40 of ‘Better Choice’ and ‘Other Choice’ products in the Healthier Vending Policy criteria at HSE level.

Figure 6 ‘Better Choice’ and ‘Other Choice’ beverage unit sales at HSE level (2016). Figure 7 ‘Better Choice’ beverages sold at HSE level (2016) by beverage category

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Executive Summary

This report was prepared by the Healthy Eating Active Living Policy Priority Programme to assess level of compliance with the provisions of the HSE Healthier Vending Policy. The National Nutrition Surveillance Centre (NNSC), University College Dublin (UCD), was commissioned to undertake the analyses of data from the vending companies. The Health Service Executive (HSE) Healthier Vending Policy was introduced in 2014 with the objective of contributing to a healthier food environment across the health service by ensuring that staff, visitors and patients have the option of choosing a healthier snack or beverage when using a vending machine on HSE premises.

The Policy applies to all vending machines for Cold Soft Drinks, Confectionery and Snacks on HSE premises. All vending machines are required to meet the following criteria:

 products are required to meet the classifications of Better Choice or Other Choice  the minimum ratio of Better Choice to Other Choice products must be 60:40 in all machines  meet branding specifications for vending machines, and display healthy message  product placement should ensure that Better Choice products are placed in prime slots  display calorie information on products alongside the price

The report provides analyses of data for the time period 2016. Data from 295 vending machines serviced by the two companies on the Framework across 89 health service sites was analysed. Health service sites include HSE sites and HSE funded sites (Section 38 and 39 Agencies).The analyses is based on the information supplied by the two companies on the Framework and in assessing compliance with the 60:40 ratio uses their classification of Better Choice and Other Choice products. The findings verified that there was very good compliance in relation to calorie posting: 98% compliance with Better Choice products and 86% compliance with Other Choice products. However, the results indicated that there was poorer compliance with the following:

• the classification of Better Choice and Other Choice • the 60:40 ratio for Better Choice and Other Choice • product placement

A total of 52 (22 snacks and 30 beverages) products were stocked by vending companies as ‘Better Choice’ products. Under the HSE Healthier Vending Policy, Better Choice products are required to

adhere to a maximum calorie ceiling and specified nutrient profile. 65% (34) of those products met the policy criteria for ‘Better Choice’ products when assessed independently by the NNSC.100% of beverages stocked as Better Choice by vending companies met the ‘Better Choice’ criteria whilst only 18% of food items met the ‘Better Choice’ criteria. Poor availability of Better Choice snack products in the market has been cited by the companies as a serious challenge at contract review meetings.

The NNSC also analysed 244 products from the Irish and UK market and this strongly indicated that the nutrient profile of the majority of snack products on the Irish market significantly exceeds the criteria for Better Choice products as set out in the HSE Healthier Vending Policy. This finding would indicate that market availability of products that meet both the specified nutrient profile and maximum calorie ceiling is limited.

Only 30% of all vending machines met the criterion of stocking Better Choice and Other Choice products to a ratio of 60:40. The drinks machines for both companies, were the only machine type that met the policy’s 60:40 ‘Better Choice’ to ‘Other Choice’ product ratio. In addition, since one in three Better Choice products were misclassified by the companies, the ratio of ‘Better Choice’ to ‘Other Choice’ would be lower in the other machine types, than those expressed in these results.

The total revenue generated from all products across all health service sites under the Framework Contract in 2016 was approximately €2 million. The largest proportion of revenue was generated by Hospital Groups. One quarter of the total revenue was returned as commission to health service sites. 38% of the commission returned was attributable to Better Choice product sales

This passive income can act as an enticement for sites to have vending machines while at the same time it can undermine efforts to create a healthier food environment and promotion of staff health and wellbeing. While the income can be small in some sites, it can be valued as it is a flexible source of revenue for sites for meeting site needs at their discretion. The contribution of vending machines as a source of income needs to be balanced against the potential for negative impact on health and wellbeing of staff and visitors.

At the end of 2017, 91% of sites had transitioned to the companies on the Framework and there are 467 machines in total on 112 HSE sites. These include machines supplied by the Framework companies, three companies not on the Framework and two sites that own their own machines and self-fill.

These analyses demonstrate that achievement of 100% compliance with all components of the current Healthier Vending Policy is challenging. The HSE will use the results of this data analyses to support the continuing implementation of the Policy and to inform the review process in 2018.

Recommendations

The recommendations are informed by the findings of the data analyses, discussion with various stakeholders including the suppliers on the Framework contract and the Healthy Eating Active Living Programme Team and National Implementation Group.

1. Discuss the findings of this report with vending companies on the framework and request to rectify misclassifications of products

2. HSE Health Business Services, Hospital Groups, Community Healthcare Organisations and other sites to work with the Healthy Eating Active Living Programme to identify next steps to improve compliance, with particular attention to the requirements in relation to HSE National Contract for Vending 2015-2020 and the application of the policy to Section 38 and 39 funded agencies

3. The Healthier Food Environment Advisory Group, established by the Healthy Eating Active Living Policy Priority Programme will use the findings of this report to inform the review process for the Healthier Vending policy scheduled for 2018 giving particular consideration to the following:

i. The criteria that apply to Better Choice snack products – remove the nutrient profile criteria and apply a calorie ceiling to all snack products. ii. The provision that milk and water (excluding flavoured/carbonated water) are the only beverages classified and offered as Better Choice. iii. Apply the existing nutrient profile criteria to Other Choice beverages. iv. Revise the monitoring and audit roles and responsibilities to provide for: a. annual compliance data collection, analyses and reporting at national level b. appropriate local monitoring, including use of standard planograms for physical audits v. Extend the scope of the policy to address the availability of Better Choice and Other Choice snack products and beverages across the retail environment in health service sites. vi. Clarify the appropriate role for snack and beverage vending/sales in the provision of catering for staff, particularly shift-workers, and visitors in health service sites.

Introduction

In the past two decades, levels of overweight and obesity in Ireland have doubled creating a significant challenge for our country. Overweight and obesity are significant risk factors for many chronic diseases such as heart disease, cancers, type 2 diabetes and respiratory problems. The Healthy Ireland (HI) Framework1 sets out a comprehensive and co-ordinated plan to improve the health and wellbeing of the people of Ireland over the coming years. ‘Healthy Ireland in the Health Services’ 2015-20172 sets out how the HSE is implementing the Healthy Ireland Framework within the health services in Ireland. To support the HSE to reduce the burden of chronic disease a number of actions are being implemented including the implementation of the Healthier Vending Policy3.

The implementation of the Policy is supported by a national procurement framework known as the HSE National Contract for Vending 2015-2020. Following a public procurement process two suppliers were appointed to the Framework in late 2015. In 2017, the Healthy Eating Active Living Policy Priority Programme undertook to assess compliance with the implementation of the Policy. The National Nutrition Surveillance Centre (NNSC-UCD) was commissioned to analyse data from vending machines on health service sites provided by the Framework suppliers for the year 2016.

This report outlines the progress of implementation of the policy in relation to:

• Mapping Health service sites with vending machines and identifying the contract arrangements • data analyses of 295 vending machines across 89 health service Health service sites in 2016 for the two companies on the framework for the HSE National Contract for Vending 2015-2020

The purpose of this report is to share the details of the data analyses in order to learn from the findings and to support on-going and future implementation. The HSE will use the results of the data analyses to inform the review of the Healthier Vending Policy in 2018.

The report outlines the background to introducing healthier vending into the HSE including information on implementation and monitoring of the policy. It outlines the methodology used and describes the results of the data analyses. The results are discussed and the report concludes with recommendations according to the obtained findings.

Policy Context The most recent data from the Healthy Ireland Survey 20174 shows that 36% of people in Ireland have a normal weight, 39% are overweight and 23% are obese. Overweight and obesity are significant risk factors for many chronic diseases which fortunately are preventable. The burden of adult obesity in financial terms in Ireland has been estimated as €1.13 billion per annum (safefood, 2012)5.

In 2017, the Department of Health under Healthy Ireland published the Healthy Food for Life6 guidelines. These guidelines clarifies that the majority products available through vending machines as not essential components of a healthy diet and recommends limiting both frequency of consumption as well as the portion size when consumed.

In response to this changing health and wellbeing profile described above, the Healthy Ireland Framework was developed by the Irish Government in 2013. This framework proposes a shift towards a broader approach to governance for health, moving beyond the health service, across national and local authorities, involving all sectors of society and the people themselves.

‘Healthy Ireland in the Health Services’ 2015-20172 sets out how the HSE is implementing the Healthy Ireland Framework within the health services in Ireland. It focuses on three priority areas; Health service Reform, Reducing the burden of Chronic Disease and Improving staff health and wellbeing.

As part of the Health Service Reform, the Healthy Eating Active Living Programme was established as one of a number of Healthy Ireland Policy Priority Programmes in 2016. The Programme co- ordinates and leads activity across the health service s to ensure implementation of two key national policies under Healthy Ireland: A Healthy Weight for Ireland: Obesity Policy and Action Plan 2016 – 20257 and Get Ireland Active! The National Physical Activity Plan for Ireland8. The Programme aims to mobilise the health services to improve health and wellbeing by increasing the levels of physical activity, healthy diet and healthier weight across services users, staff and the population as a whole, with a focus on families and children.

Healthier Food Environment Part of implementing ‘Healthy Ireland in the Health services’ involves the HSE using the physical environment, such as the HSE work setting, to influence which foods are available to eat. The HSE is the largest employer in the State with 100,000 employees and services delivered in over 2,500 workplaces which include hospitals, community health care facilities and administration sites. Many of these sites are venues where food is purchased and eaten. The aim is to change from the current

“obesogenic” environment, where unhealthy foods are readily available in most places, to one that facilitates the consumption of healthier food and drink.

It is important that the HSE shows leadership by providing healthier eating environments for their staff, visitors and patients and in so doing be an exemplar employer of good practice. Creating a healthier food environment also supports the strategic priority of improving staff health and wellbeing.

There is a wide ranging programme of initiatives in relation to food and nutrition in HSE settings that contribute to creating this healthier food environment:

 HSE Healthier Vending Policy  HSE Calorie Posting Policy9 (for staff & visitor food)  Development of a national hospital food policy and implementation toolkit in 2018  Development of minimum nutritional standards for catering in health and social care for staff and visitors in 2018  Quality Improvement Programme for nutrition and hydration across services  Posting of allergenic ingredients in line with legislation introduced in December 2014

Actions 62, 78, 82, and 84 of Healthy Ireland in the Health Services refer to implementing the HSE Healthy Food & Nutrition Policy, the Healthier Vending Policy and the Calorie Posting Policy.

HSE Healthier Vending Policy Vending machines provide easy access to sugar-sweetened beverages, confectionary and snacks that have a long shelf-life and little nutritional value. In general, snack products are high in fat, sugar and salt (HFSS) and are linked to an increased risk and incidence of chronic diseases as well as contributing to high levels of obesity. Vending machines are not intended to be a source of nutritious food over a 24 hour period when other catering facilities are closed. Increased availability of sugar- laden foods and beverages in vending machines accompanies the increased prevalence of snacking in our culture. The Healthy Ireland Survey 2017 reports on consumption patterns of these “top shelf” food items from the revised Healthy Food for Life guidelines6. It reports that 35% of people surveyed consume at least one of the food categories (sweets, cakes and biscuits, salted snacks, pastries and fried foods) on a daily basis and 91% consume at least one of them each week. The survey also reports that 36% of individuals indicate that they are trying to lose weight, with 69% of those categorised as obese trying to address the issue. The most common action taken to lose weight is doing more exercise (68%), followed by eating fewer calories (56%).

The introduction of the Healthier Vending Policy by HSE Management in February 2014 aimed to create a healthier food environment by increasing healthier choices and reducing unhealthy food choices in vending machines. It provided the opportunity to improve nutrition and promote knowledge of healthy eating across the population whilst still allowing for free choice and generation of income for hosting sites. The Policy applies to all vending machines for Cold Soft Drinks, Confectionery and Snacks on HSE premises. The policy comprises six elements addressing food and beverage provision, communications, advertising, food safety, product placement, calorie posting, vending of non-food items and charity boxes. In summary, under the policy, all vending machines are required to meet the following criteria:

 products are required to meet the classifications of Better Choice or Other Choice.  the minimum ratio of Better Choice to Other Choice products must be 60:40 in all machines  meet branding specifications for vending machines, and display healthy message  product placement should ensure that Better Choice products are placed in prime slots  display calorie information on products alongside the price

The proportion of healthy product (Better Choice) versus the proportion of traditional vended products (Other Choice) may be adjusted upwards only in favour of a higher proportion or 100% of healthy (Better Choice) products, at the discretion of local management.

“Better Choice” and “Other Choice” Products are defined as follows;

Classification of food products in vending machine. Better Choice Other Choice Energy ≤150kcal per packet ≤250kcal per packet

Total Fat ≤ 20g/100g Not restricted

Saturated Fat ≤ 5g/100g Not restricted Sugar ≤ 15g/100g Not restricted Salt/Sodium ≤ 1.5g/0.6g/100g Not restricted

Healthier vending machines are white in colour with a small HSE logo and Healthy Ireland (hi) logo at the bottom of the front and side panels. Better Choice products are identified by lime green containers or collars. The main caption on the machine is “It’s all about choice… make yours a healthy one”.

Three other key messages displayed in lime green bubbles are:

1. Want a healthier snack? Choose the green options 2. Save your smile, drink water 3. Keep your snack to 150 calories

A note on Healthy Ireland (hi) logo branding

Feedback from people implementing the policy and consumers has shown that there is concern about associating the Healthy Ireland (hi) logo with vending machines that sell products that are classified as Other Choice for example sugar sweetened beverages (SSBs). Inclusion of SSBs may be seen to undermine the potential for Healthy Ireland branding and messaging to stimulate behaviour change. In some countries, healthy vending machines are required to vend 100% Better Choice products. Since the Policy was introduced in 2014 the Healthy Ireland landscape has changed. In 2017, the Department of Health under Healthy Ireland published Healthy Food for Life guidelines. These guidelines identify that the majority of products available through vending machines as not essential components of a healthy diet and recommends limiting both frequency of consumption as well as the portion size when consumed.

From May 2018, the Irish Government will introduce a Sugar Tax on SSBs in a step to reduce their consumption because of the proven negative impact on weight and dental health.

Policy Implementation The implementation of the Policy is supported by a national procurement framework established in February 2015, known as the HSE National Contract for Vending 2015-2020. Following a public procurement process, two companies were appointed to the framework. Both companies on contract must provide vending services as per the HSE’s Healthier Vending Policy described above. Following the establishment of the national procurement framework, no budget holder should enter into any contractual arrangements for vending services with any others outside the companies that are on the framework. The Policy provides for a transition period so that pre-existing contracts are honoured. As pre-existing local contracts expire, they can only be replaced by contracts awarded on foot of competition with framework companies. All future and existing contracts for vending services must comply with this Policy.

It is the responsibility of the General Manager on each site to ensure that those involved

in the vending process comply with this Policy through monitoring, audit and review.

A note on compliance requirements of Section 38 and 39 funded organisations

The HSE National Contract for Vending 2015-2020 states that voluntary hospitals may avail of the policy if they so wish.

To strengthen compliance with the policy, it has been named in Service Level Agreements for Section 39 agencies in 2018. This will mean that agencies funded by the HSE through Section 39 will need to comply with the policy.

Work is on-going to strengthen compliance for Section 38 funded organisations.

Currently, 91% of sites have transitioned to the companies on the framework (Appendix 1). However, there are still some sites that have pre-existing contracts, contracts that are part of other catering contracts, contracts that have rolled over, or sites that are not on contract with a vending company as they own their machines and self-fill and sites that have contracts with companies not on the framework. The Healthy Ireland Project Managers/Leads in each of the Hospital Groups and Health & Wellbeing Leads of Community Healthcare Organisations are working with these sites to facilitate the transition to adhere to the Healthier Vending Policy.

Monitoring of Healthier Vending Policy The policy outlines that implementation and monitoring are to be devised at a local level. As referenced above, it is the responsibility of the General Manager on each site to ensure that those involved in the vending process comply with this Policy through monitoring, audit and review. A minimum of annual audit is required and an audit template is provided in the policy to facilitate this process.

Local audits under the policy have been carried out by St. Luke’s Hospital Kilkenny in 2016 and the RCSI Hospital Group in 2017 and submitted to the Healthy Eating Active Living Programme. In addition, the HSE has received several contacts from consumers via Twitter highlighting the content of machines in various locations and questioning their compliance with the policy. Discussions at contract review meetings with the suppliers flagged the need to make a global objective assessment of policy compliance.

At a national level, the Healthy Eating Active Living Programme is accountable for the implementation of the policy. The programme has been working with Hospital Groups, Community Healthcare Organisations and other HSE structures during 2017 to identify sites that have moved to the framework and sites that are in transition (Appendix 1). The programme has established a baseline position for 2016 which has contributed to the development of a national database of

vending machines with relevant information on numbers, contract details and contact persons. A number of queries arose from this process in relation to the policy and a Frequently Asked Questions document provides clarification on these. The FAQ document is available on the HSE website. https://www.hse.ie/eng/about/who/healthwellbeing/our-priority-programmes/heal/healthier- vending/

The programme has responded to two Parliamentary Questions on Healthier Vending in 2017 in relation to Hospital Group compliance with the policy.

In 2017, the programme commissioned the National Nutrition Surveillance Centre (NNSC-UCD) to analyse data from vending machines from the year 2016 and onwards. This will allow the HSE to monitor compliance with the Policy and provide a baseline for monitoring changes in product sales from vending machines and changes in consumption patterns over the coming years.

The Policy includes a provision in relation to fundraising charity boxes that sell snack and beverages. This element of the Policy has not been addressed in this report.

Methodology

In 2017, the Healthy Eating Active Living Programme commissioned the National Nutrition Surveillance Centre (NNSC) to analyse data from the two vending machines companies on the framework for the Health Service Executive (HSE) National Contract for Vending 2015-2020. A Scope of Work document outlined the evaluation to be conducted by the NNSC during this period (Appendix 3).

Data collection

Meetings were held separately with both companies, the NNSC and the Healthy Eating Active Living Programme representatives to discuss the Scope of Work and gain commitment from both companies to furnish the required data and to do it within an agreed time frame. The process of transferring data took place from May to August and data analyses commenced in August 2017. Companies sent the datasets to the Healthy Eating Active Living Programme, who forwarded the datasets onto the NNSC after ensuring that the companies’ names were anonymous. These analyses were conducted using 2016 sales (revenue and units sold) and nutritional data provided by the vending companies. A total of 295 vending machines across 89 health service sites were included. The statistical software package SPSS v.14 and Microsoft Excel were used to analyse the data

Product nutritional analyses

A list of products stocked in the vending machines was provided by each company. These products were categorised into ‘Better Choice’ and ‘Other Choice’ products by the NNSC according to the ‘Healthier Vending’ criteria (see table below) using the nutrient values available in the labels of the products and/or on the manufacturers’ website.

‘Better Choice’ and ‘Other Choice’ criteria for products as per the HSE ‘Healthier Vending’ Policy 2016. Product Criteria ‘Better Choice’ Kcals ≤150 kcals per packet Fat ≤20g per 100g Saturated Fat ≤5g per 100g Sugar ≤15g per 100g Salt/Sodium ≤1.6/ per 100g ‘Other Choice’ Kcals ≤250 kcals per packet

60:40 analyses and product placement

Company 1

A sample planogram1 for each type of vending machine (snack, drinks and combination) was provided by Company 1.

In order for a vending machine to comply with the ‘Healthier Vending’ policy, ‘Better Choice’ and ‘Other Choice’ products must be stocked at a ratio of 60:40. The planograms provided were used to establish the proportion of each product type stocked in each vending machine type. The vending machine types were then classified as ‘meets policy’ and ‘does not meet policy according to the sample planograms. The proportion of machines that met the policy was calculated using the master list of vending machines, indicating machine location and type, provided by the company.

The policy also requires that the ‘Better Choice’ products are placed in prime slots in the vending machine. Prime slots were defined as those in rows at eye-level so as to encourage purchase over products stocked elsewhere in the machine (i.e. ‘Other Choice’ products). The planograms were used to visually assess the placement of ‘Better Choice’ and ‘Other Choice products in the vending machines.

Company 2

Company 2 provided a planogram for every vending machine supplied to health service sites in 2016. In order to carry out the 60:40 analyses and the visual analyses of the product placement we selected a random sample of each vending machine type (snack, drink and combination) using an online randomisation tool. The proportion of ‘Better Choice’ and ‘Other Choice’ product in each machine type was then calculated and the machines were classified as ‘meets policy’ and ‘does not meet policy’ according to the sample planograms. The proportion of machines that met the policy was calculated using the master list of vending machines, indicating machine location and type, provided by the company.

The placement of ‘Better Choice’ product in prime slots was assessed visually using the random samples generated.

It is important to note that it was not possible to perform a physical visual audit for products placement in each machine, only the sample planograms provided by the companies were used to carry out this evaluation.

Beverage Sales

The beverage sales data provided by both companies was analysed in order to assess the total quantity of each beverage type sold and the proportion of total beverage sales sold in 2016. This assessment was carried out at two levels. The initial assessment was carried out for beverages categorised as ‘Better Choice’ and ‘Other Choice. ‘Better Choice’ beverages were then split up into three broad categories: water, diet soft drinks, and fruit juices. Water was further sub-categorised into 3 sub-categories: still, sparkling and flavoured. The total sales (units sold) and proportion of total beverage sales (2016) were calculated at site level, Hospital Group/CHO/National/Corporate and Other Services level.

Results The current analyses are based on the 2016 dataset from vending machines across health service sites provided by the suppliers on the HSE National Contract for Vending Services 2015-2020. Data from 295 vending machines across 89 health service sites were included in the analyses. The 89 sites include HSE sites and HSE funded sites (Section 38 and 39 Agencies) total of 117 products were analysed.

1.1 Product nutritional analyses: ‘Better Choice’ and ‘Other Choice’ products.

1.1.1 Products stocked as ‘Better Choice’ products.

A total of 52 (22 snacks and 30 beverages) products were stocked by vending companies as ‘Better Choice’ products. 65% (34) of those products met the policy criteria (Table 1). Of the products that did not meet the criteria, 56% exceeded one criterion, 22% exceeded 2 criteria and 22% exceeded 3 criteria. 89% of the products exceeded at least one criterion by over 10% whereas two products (11%) exceeded one criterion by 7%.

The nutritional information for products stocked as ‘Better Choice’ products is displayed in Tables 4 & 5. The majority of products that met the ‘Better Choice’ criteria were beverages (88.2%). 100% of beverages met the ‘Better Choice’ criteria. All products that were stocked as ‘Better Choice’ products but did not meet the criteria were snack items. 18% of snack items met the ‘Better Choice’ criteria. Although all products, except one, met the energy criterion (≥150 kcals), the criteria for fat (≤20g/100g), sugar (≤15g/100g) and salt (≤1.5g/100g) were not met. Every product that exceeded the fat limit also exceeded either the sugar limit or the salt limit. 56% of the products contained more than 15g of sugar per 100g and 44% of the products contained more than 1.5g of salt per 100g.

Table 1. Breakdown of products stocked by companies as ‘Better Choice’ products that met/did not meet the Healthier Vending Policy ‘Better Choice’ classification in 2016. All products Snacks Beverages n (%) n (%) n (%) Meets criteria 34 (65.4) 4 (18.2) 30 (100) Does not meet criteria 18 (34.6) 18 (81.8) 0 5-10% over limit 2 (11.1) 2 (11.1) 0 10% + over limit 16 (88.9) 16 (88.9) 0 Total (n) 52 22 30 Data displayed as (n) and % of totals.

1.1.2 Products stocked as ‘Other Choice’ Products.

In 2016, there were a total of 65 (51 snacks and 14 beverages) products stocked by the vending companies as ‘Other Choice’ products (Tables 6 & 7). 87.7% of these products met the ‘Other Choice’ energy criterion (≤250kcal per packet). In total, seven food items exceeded the energy limit per packet, ranging between 20kcals (8%) and 44kcals (18%) over the 250kcal limit. One beverage stocked as an ‘Other Choice’ product contained 270kcals per packet, 8% over the limit of 250kcal (Table 2).

Table 2. Breakdown of products stocked by companies as ‘Other Choice’ products that met/did not meet the Healthier Vending Policy ‘Other Choice’ classification in 2016. All products Snacks Beverages N (%) n (%) n (%) Meets criteria 57 (87.7) 44 (86.3) 13 (92.9) Does not meet criteria 8 (12.3) 7 (13.7) 1 (7.1) 5-10% over limit 3 (37.5) 2 (28.6) 1 (100) 10% + over limit 5 (62.5) 5 (71.4) 0 Total (n) 65 51 14 Data displayed as (n) and % of totals.

1.1.3 Identification of additional ‘Better Choice’ products. Following the current audit, the HSE provided a list of 244 products available on the Irish and UK market for nutritional analyses in order to provide both vending companies with additional ‘Better Choice’ product options. These analyses resulted in the identification of an additional 13 ‘Better Choice’ snack products and 109 ‘Better Choice’ beverage products not currently stocked by the vending companies.

Overall, the nutrient content of a total of 361 products that could potentially meet the policy as ‘Better Choice’ or ‘Other choice ‘products were analysed. This included the products stocked by the companies and the products available in the market that are not stocked by the companies. Among these, 156 products, 17 snacks and 139 beverages, were classified as ‘Better choice’ products (Table 3).

Table 3. Products that meet the Healthier Vending Policy ‘Better Choice’ classification in 2016 including those stocked by the companies and those available in the market that were not stocked by the companies. Total Companies New products n % n % n % All products 156 - 34 - 122 - Snacks 17 10.9 4 11.8 13 10.7 Beverages 139 89.1 30 88.2 109 89.3

Table 4. Products stocked by companies as ‘Better Choice’ products that meet the Healthier Vending Policy criteria (n=34). Product Name Kcals per packet Total Fat per 100g Total Saturated Fat Total Sugar per 100g Total Salt/Sodium per 100g per 100g Policy Criteria ≤150 Kcals/packet ≤20g/100g ≤5g/100g ≤15g/100g ≤1.5g/100g | 0.6g/100g Snacks (N=4)

Sesame Stick 30g 134 17.9 1.7 2.3 Trace Extra Mints 28g 68 1.2 1.2 0 0 Extra Peppermint Gum 39g 59 0 0 0 0 Tayto Treble Crunch Sweet Chilli 20g 87 11 1.5 14 1.5 Beverages (N=30) Water (n=10) Ballygowan Sparkling Water 500ml 0 0 0 0 0 Ballygowan Still Water 500ml 0 0 0 0 0 RiverRock Still Water 500ml 0 0 0 0 0 RiverRock Still Water 750ml 0 0 0 0 0 RiverRock Strawberry Sugar Free Still 6 0 0 0 0 500ml Classic Sparkling Blackberry Water N/A 3 0 0 0 500ml Classic Sparkling Lemon &Lime Water N/A 3 0 0 0 500ml Classic Citrus water 500ml 3 0 0 0 0 Classic forest fruit water 500ml 3 0 0 0 0 Vita Coca Natural Water 330ml 62 0 0 4.6 0.01* Continued. *indicates Sodium content. Data displayed as g/100g

Table 4 continued. Products stocked by companies as ‘Better Choice’ products that meet Healthier Vending Policy criteria (n=34). Product Name Kcals per packet Total Fat per 100g Total Saturated Fat Total Sugar per 100g Total Salt/Sodium per 100g per 100g Policy Criteria ≤150 Kcals/packet ≤20g/100g ≤5g/100g ≤15g/100g ≤1.5g/100g | 0.6g/100g Fruit Juice (n=11)

Fruice Orange juice 330ml 149 0 0 9.1 0.01 Vita Coca Lemonade 330ml 96 0 0 6.3 0.01* Oasis Citrus Punch NC 500ml 90 0 0 4.1 0.08 Oasis Summer Fruits NC 500ml 86 0 0 4.1 0.08 Robinsons Fruit Shoot Ora & Pin 275ml 72 0 0 8 Trace Robinsons Fruit Shoot Blk/Ap 275ml 14 Trace 0 0.8 0.07 Vit Hit Immunitea Dragon 500ml 35 0 0 1.3 0.01 Vit Hit Berry Boost 500ml 15 0 0 0.88 0.04 Vit Hit Detox 500ml 36 0 0 1.2 0.02 Vit Hit Lean Green 500ml 36 0 0 1.3 0.02 Vit Hit Revive 500 ml 20 0 0 1 0 Diet Soft Drinks (n=9) Fanta Zero Orange 500ml 20 0 0 0.8 0 Sprite Zero 500ml 5 0 0 0 0.05 7 up Free 330ml 3 0 0 0 Trace Coca Cola Zero 500ml 2 0 0 0 0.02 Diet Coke 500ml 2 0 0 0 0 Pepsi max 500ml 2 0 0 0 0 Diet Coke 330ml 1 0 0 0 0 Pepsi max 330ml 1 0 0 0 0

Coca Cola Zero 330ml 1 0 0 0 0.02

*indicates Sodium content. Data displayed as g/100g

Table 5. Products stocked by companies as ‘Better Choice’ products that did not meet Healthier Vending Policy criteria, by number of criteria exceeded (n=18).

% Grams % Total Grams % Total % Grams Kcal Total Fat Grams Total Salt % over Product Name over over over Saturated Fat over over Sugar over over (packet) (100g) over limit (100g) limit limit limit limit (100g) limit limit (100g) limit limit

Policy criteria ≤150Kcal ≤20g ≤5g ≤15g ≤1.5g

1 criterion exceeded (n=10) Tic Tacs mint 18g 71.5 0 0.5 0 0 0.5 0 0 94.5 79.5 530 0.03 0 0 Tic Tacs Lime/orange 71.5 0 0.5 0 0 0.5 0 0 94.5 79.5 530 0.03 0 0 18g Special K raspberry & 90 0 10 0 0 5 0 0 35.9 20.9 139 0.6 0 0 chocolate 22g Nutrigrain Strawberry 131 0 7.7 0 0 2.9 0 0 33 18 120 0.8 0 0 37g Nutrigrain Apple 37g 131 0 7.7 0 0 2.9 0 0 33 18 120 0.8 0 0 Nutrigrain blueberry 131 0 7.7 0 0 2.9 0 0 33 18 120 0.8 0 0 37g King Velvet Crunch 85 10.5 0 0 0 1.5 0 0 16 1 7 1.5 0 0 Cheese & Onion 20g Pretzels 18g 70 7.5 0 0 0 1.5 0 0 2.8 0 0 3.5 2 133 Snack A Jacks Salt 106 7.7 0 0 0 0.8 0 0 1.8 0 0 2.8 1.3 87 and Vinegar 26g Kelkin Rice Cake bar 94 19 0 0 0 4.5 0 0 15 0 0 1.6 0.1 7 20g

2 criteria exceeded (n=4) Tayto Treble Crunch 99 0 25 5 25 3.1 0 0 3.7 0 0 2.8 1.3 87 cheese & Onion 20g Popcorn 30g 134 0 18.8 0 0 12.9 7.9 158 0.2 0 0 2.3 0.8 52

Popcorn 15g 66 0 18.8 0 0 12.9 7.9 158 0.2 0 0 2.3 0.8 52 Tayto Snax Cheese & 20 87 0 27.7 7.7 39 2.3 0 0.0 1.8 0 0 1.8 0.3 Onion 17g

3 criteria exceeded (n=4)

Chilli Bites 25g 148 0 38.4 18.4 92 18.4 13.4 268 12.8 0 0 2.4 0.9 60

Timeout Wafer 21.2g 112 0 29 9 45 16 11 220 45 30 200 0.3 0 0 Nature Valley Sweet & 139 0 24 4 20 9.5 4.5 90 22 7 47 0.8 0 0 Nutty 30g Rice Krispie 199 33 12 0 0 7 2 40 32 17 113 0.8 0 0 Marshmallow 28g

Data presented in Kcal or grams. % over limit; percentage above ‘Better Choice’ criteria for nutrients.

Table 6. Food products stocked by companies as ‘Other Choice’ products in 2016 (n=51).

Product Name Kcals per packet Kcals over limit % over limit Policy criterion ≤250kcal per packet Polo Mint Sugar Free 33.4g 80 0 0 Special K Biscuit Moments Strawberry 25g 102 0 0 Special K Biscuit Moments Chocolate 25g 104 0 0 Kit kat 2 finger 20.5g 104 0 0 Rice Krispies Squares 28g 119 0 0 Mentos Chewy Mint 38g 148 0 0 Orbit Spearmint 100g 155 0 0 Orbit peppermint 100g 155 0 0 Rowntrees Randoms 50g 164 0 0 Nutrigrain Raisin bake 45g 168 0 0 Eat Real Cashew & Cranberry 40g 173 0 0 Maynards Wine Gums Roll 52g 180 0 0 Nutrigrain Elevenses Choco Chip 45g 182 0 0 Maltesers Teasers 35g 186 0 0 Maltesers 37g 187 0 0 Nutri grain Breakfast biscuit 44g 189 0 0 Nature valley Oats & honey 42g 192 0 0 Eat real Fruit & Nut 40g 196 0 0 Aero 36g 192 0 0 Nature Valley Oat Choc 42g 196 0 0 Tayto Cheese & Onion 34.5g 197 0 0 Doritos Chilli Heatwave 40g 198 0 0

Continued. Data displayed as kcals per packet and % over ≤250kcals limit

Table 6 continued. Food products stocked by companies as Other Choice products 2016 (n=51).

Product Name Kcals per packet Kcals over limit % over limit

Policy criterion ≤250kcal per packet Tayto Salt & Vinegar 34.5g 199 0 0 Aero Mint 46g 199 0 0 Kit kat chunky 40g 203 0 0 Cadbury Snack Shortcake 43g 204 0 0 Kitkat 4 Finger 48g 209 0 0 Chocolate Raisins 50g (the good snack co.) 211 0 0 Cadburys Twirl 43g 228 0 0 Galaxy Standard 42g 229 0 0 Hunky Dory Salt & Vinegar 45g 234 0 0 Hunky Dory Buffalo 45g 235 0 0 Hunky Dory Cheese & Onion 45g 237 0 0 Chilli & Cashew Nuts 45g (the good snack co.) 240 0 0 Extra Mints 100g 240 0 0 Dairy milk 45g 240 0 0 Galaxy Caramel 48g 240 0 0 Mars bar 53g 244 0 0 Kinder Bueno 48g 246 0 0 Twix 50g 248 248 0 0 Salted Cashew & Peanut 35g 249 0 0 Continued. Data displayed as kcals per packet and % over ≤250kcal limit

Table 6 continued. Food products stocked by companies as Other Choice products in 2016 (n=51)

Product Name Kcals per packet Kcals over limit % over limit

Policy criterion ≤250kcal (per packet)

Fruit & Nut Mix 40g 249 0 0 Yorkie Original 46g 249 0 0 Starbar 49g 249 0 0 Exceed energy criterion (n=7) Chocolate Peanuts 40g (the good snack 270 20 8 co.) 9 Bar Flax 50g 273 23 9 9 Bar Pumpkin 50g 275 25 10 Bounty 57g 278 28 11 Cadbury’s Golden Crisp 49g 278 28 11 Dairy milk Std. 53g 280 30 12 Snickers 58g 294 44 18

Data displayed as Kcals per packet and % over ≤250kcal limit

Table 7. Beverages stocked by companies as ‘Other Choice’ products in 2016 (n=14). Product Name Energy per Packet % Over limit (Kcals) Policy Criterion ≤250kcals Sprite 500ml 250 0

Lucozade Orange Barley 380ml 240 0

7 up 500ml 218 0 Coca Cola 500ml 215 0 Fanta Orange 500ml 210 0 Club Orange 330ml 182 0 Fanta Orange 330ml 165 0

Pepsi 330ml 144 0 Lucozade Raspberry 500ml 141 0 Lucozade Sport 500ml 141 0 Coca Cola 330ml 139 0 7 up 330ml 135 0

Ribena Tetra Pack 288ml 121 0

Exceed energy criterion (n=1)

Lucozade Energy 330ml 270 8 Data displayed as Kcals per packet

1.2 60:40 ratio analyses and product placement

In order to comply with the Healthier Vending policy machines must stock ‘Better Choice’ and ‘Other Choice’ products to a ratio of 60:40 (%). Another requirement of the Healthier Vending Policy is the placement of ‘Better Choice’ products in prime slots in vending machines. These requirements were assessed using the planogram information provided by companies as described in the methodology section.

Prime slots were defined as the rows in the vending machine at eye level, prompting products placed there to be chosen over products placed elsewhere in the machine. Prime slots were the two top rows for all types of machines, regardless of the company. It is important to note that the results below are based on standard planograms provided by the companies; therefore, it is crucial to maintain the placement of products over time to ensure that the policy is met in this regard.

1.2.1 60:40 ratio analyses and product placement at company level

Company 1 - 60:40 ratio analyses

The analyses of the 60:40 ratios in Company 1 machines was completed using three samples of standard machine layouts supplied by the company. ‘Better Choice’ products were classified as products that met policy criteria according to company classification of ‘Better Choice’ vs ‘Other choice’ data. Although all three sample machines had more ‘Better Choice’ products available compared to ‘Other Choice’ products, the drinks machines was the only machine type that met the policy’s 60:40 ‘Better Choice’ to ‘Other Choice’ product ratio (Table 8). 79% of the products in the drinks machines were ‘Better Choice’ products, whereas 56% and 57% of the product snacks machines and combination machines, respectively, were ‘Better choice’ products. Although these two types of machines did not comply with the policy, they were close to the 60:40 ratio based on company classification of ‘Better Choice’ and ‘Other Choice’ products.

Table 8. Number and proportion of ‘Better Choice’ and ‘Other Choice’ products stocked by Company 1, by vending machine type using company data. ‘Better Choice’ products ‘Other Choice’ products Meets 60:40 Machine type n (%) n (%) criteria Snacks 20 (55.5) 16 (44.4) No Machine Drinks 38 (79.2) 10 (20.8) Yes Machine Combination 25 (56.8) 19 (43.2) No Machine Data displayed as n and % of total products. Analyses performed using products classification supplied by company.

Company 1 - Product placement analyses

Figure 1 depicts the placement of ‘Better Choice’ and ‘Other Choice’ products in the three sample machines. Red arrows depict the prime slots. All three machines had a higher proportion of ‘Better Choice’ products placed in the prime slots. The snack machine had the highest proportion of ‘Better Choice’ options in prime slots (100%), followed by 81% in the drinks machine and 67% in the combination machine. Indeed, only the snacks machine met the product placement policy as all the products placed in prime slots were ‘Better Choice’ products.

Combination Machine Snack Machine Drinks Machine Prime Slots Prime Slots Prime Slots b b o o b b b b b b b b b o o o b o b b o b b b b b b b b b b b b b b b

o o o o o o o o o b b b b b b b b o o o b b b b b b b o b o b o b b b b b b b b b b b b b b b b b b o o b o o b b o o o b b b b b b b b b b o o b b o o o o o o o o o o b b b b o o o o

b ‘Better Choice’ Product o ‘Other Choice’ Product No product placed , only 4 products per row according to machine model Figure 1 Placement of 'Better Choice' and 'Other Choice' products in Company 1 vending machines. Prime Slots are defined as those at eye level, prompting products placed here to be chosen over products placed in other slots.

Company 2 - 60:40 ratio analyses

Company 2 provided a planogram for every vending machine supplied to health service sites in 2016. As it was not practical to analyse the product placement for each individual machine, the product placement analyses for Company 2 was carried out using random samples of each machine type. Random samples were generated using an online randomisation tool and a list of machines provided by the company. ‘Better Choice’ products were classified as products that met policy criteria according to company data.

Drinks machines were the only machine type that met the 60:40 ratio of ‘Better Choice’ to ‘Other Choice’ products (67:33) (Table 9). Both types of Snack machine had a lower proportion of ‘Better Choice’ products compared to ‘Other Choice’ products: 20:80 and 32:68, respectively for type 1 and type 2 machines. Neither of the combination machines met the 60:40 ratio. The ‘Better Choice’ to ‘Other Choice’ ratio was 42:58 for type 1 of the combination machines (42:58) whereas Type 2 combination machines stocked both product types in equal proportions.

Table 9. Number and proportion of ‘Better Choice’ and ‘Other Choice’ products stocked by Company 2, by vending machine type. ‘Better Choice’ Products ‘Other Choice’ Products Machine Type Meets 60:40 Criteria n (%) n (%) Snacks Machine Type 1 (36 Slots) 7 (19.5%) 29 (80.5%) No Type 2 (40 slots) 13 (32.5%) 27 (67.5%) No Combination Machine Type 1 (36 slots) 15 (41.6%) 21 (58.4%) No Type 2 (36 slots) 18 (50%) 18 (50%) No Drinks Machine Type 1 (45 slots) 30 (66.7%) 15 (33.3%) Yes Data displayed as number of products (n) and % of total products. Analyses performed using random samples of machine types. Analyses performed using products classification supplied by company.

Company 2 - Product placement analyses

The proportion of ‘Better Choice’ products placed in prime slots varied by vending machine type (Figures 2-4). Prime slots are pointed out with the red arrows. Only drink machines met the product placement policy as all products (100%) placed in the prime slots were ‘Better Choice’ products, reflective of the increased proportion of ‘Better Choice’ products stocked in the vending machine (Figure 3). 42% of the products placed in prime slots in the 36 slot (type 1) snack (Figure 2) and in

the combination machine type 1 were ‘Better Choice’ products (Figure 4). In the 40 slot (type 2) snack machine a higher proportion of ‘Better Choice’ products (63%) were placed in prime slots (Figure 2). However, in the second combination machine type 2 only 33% of products in the prime slots were classified as ‘Better Choice’ products (Figure 4).

Snack Machine (type 1) Snack Machine (type 2)

Prime Slots Prime Slots

o o o b b b b b b b b b b b

b b o o o o b b o o o o o o

o o o o o o o o o o o b o o o o o o o o

o o o o o b b o b b o o o o

o o o o o o o o o o o o o o

b ‘Better Choice’ Product o ‘Other Choice’ Product Figure 2 Placement of 'Better Choice' and 'Other Choice' products in Company 2 snack machines. Prime Slots defined as those at eye level, prompting products placed here to be chosen over products placed in other slots.

Drinks Machine

Prime Slots

b b b b b b b b b

o o o o o o o o o

o o o o o o b b b

b ‘Better Choice’ Product

o ‘Other Choice’ Product

Figure 3. Placement of 'Better Choice' and 'Other Choice' products in Company 2 drink machines. Prime Slots defined as those at eye level, prompting products placed here to be chosen over products placed in other slots.

Combination Machine (type 1) Combination Machine (type 2) Prime Slots Prime Slots

o o b b b b o o b b b b

o o o o b o o o o o o o

o o o b o o o o o b o o

o o b b b b o o b b b b

b b b b b o b b b b b o

o o o o o o o o b b b b

b ‘Better Choice’ Product o ‘Other Choice’ Product

Figure 4. Placement of 'Better Choice' and 'Other Choice' products in Company 2 combination machines. Prime Slots are defined as those at eye level, prompting products placed here to be chosen over products placed in other slots

1.2.2. Percentage of machines that met policy at site level

As already mentioned, the machines within the Healthier Vending policy machines must stock ‘Better Choice’ and ‘Other Choice’ products to a ratio of 60:40 (%). According to the analyses carried out in section 1.2.1, the different vending machines types, that is, snack machine, combination machine and drinks machines, were classified as meeting the 60:40 criteria or not. Based on the type of machine(s) available in each site, the number of machines per site that complied with the 60:40 policy was computed. In 2016, 30% of all vending machines met this criterion at HSE level (Figure 5). At site level and at Hospital Group/CHO/National/Corporate and Other Services level this ratio varied (Table 10). This percentage was worked out from the planogram information provided by companies as described in the methodology section. The beverage machine was the only machine type that met the policy’s 60:40 Better Choice’ to ‘Other Choice’ products ratio.

Met Policy Did Not Meet Policy

30%

70%

Figure 5. Proportion of vending machines (n=295) meeting the ratio 60:40 of ‘Better Choice’ and ‘Other Choice’ products in the Healthier Vending Policy criteria at HSE level

Table 10. Proportion of vending machines meeting the ratio 60:40 of ‘Better Choice’ and ‘Other Choice’ products at site and by Hospital Group/CHO/National/Corporate and Other Services level based on nutritional information provided by vending companies. Site Name Number of machines Machines meeting policy Machines not meeting policy N n % n %

Hospital Group Total 223 (75.5%)* 68 30.5% 155 69.5% CHO Total 59 (20.0%)* 17 28.8% 42 71.2% National/Corporate and Other Services Total 13 (4.5%)* 3 23.1% 10 76.9% HSE Total 295 88 29.8% 207 70.2%

Children's Hospital Group Total 8 5 62.5% 3 37.5% Temple Street Hospital 8 5 62.5% 3 37.5% Dublin Midlands Hospital Group Total 29 10 34.5% 19 65.5% Midland Regional Hospital, Portlaoise 4 0 0.0% 4 100.0% Naas General Hospital 7 2 28.6% 5 71.4% St. Luke's Hospital Rathgar 4 0 0.0% 4 100.0% St. Luke's Hospital, James Street 1 0 0.0% 1 100.0% St. Luke's Radiation, Beaumount 1 0 0.0% 1 100.0% Tallaght Hospital, Dublin 2 2 100.0% 0 0.0% Midland Regional Hospital, Tullamore 10 6 60.0% 4 40.0% Continued. *% of total vending machines (N).

Ireland East Hospital Group Total 54 13 24.1% 41 75.9% Cappagh National Orthopaedic Hospital, Dublin 4 1 25.0% 3 75.0% Ely Hospital Wexford 1 0 0.0% 1 100.0% Midland Regional Hospital, Mullingar 6 2 33.3% 4 66.7% Our Lady’s Hospital, Meath 2 0 0.0% 2 100.0% 3 2 66.7% 1 33.3%

Royal Victoria Eye and Ear Hospital, Dublin 2 0 0.0% 2 100.0% St. Luke’s Hospital, Kilkenny 3 2 66.7% 1 33.3% St. Michael’s Hospital, Dún Laoghaire 2 0 0.0% 2 100.0% St. Vincent’s University Hospital, Dublin 22 4 18.2% 18 81.8% Wexford General Hospital 9 2 22.2% 7 77.8% RCSI Hospital Group Total 35 6 17.1% 29 82.9% Beaumont Hospital, Dublin 12 3 25.0% 9 75.0% Cavan General Hospital 4 0 0.0% 4 100.0% Louth County Hospital, Dundalk 1 0 0.0% 1 100.0% Monaghan Hospital 1 0 0.0% 1 100.0% Our Lady of Lourdes Hospital, Drogheda 12 2 16.7% 10 83.3% Rotunda Hospital, Dublin 5 1 20.0% 4 80.0% Continued. *% of total vending machines (N).

South/South West Hospital Group Total 64 31 48.4% 33 51.6% Bantry General Hospital 3 1 33.3% 2 66.6% Cork University Hospital 11 3 27.3% 8 72.7% Lourdes Orthopaedic Hospital, Kilcreene 2 0 0.0% 2 100.0% Mallow General Hospital 2 2 100.0% 0 0.0% Mercy University Hospital 11 8 72.7% 3 27.3% South Infirmary Victoria University Hospital 3 2 66.6% 1 33.4% South Tipperary General Hospital 12 5 41.7% 7 58.3% University Hospital Kerry, Tralee 7 4 57.1% 3 42.9% University Hospital Waterford 13 6 46.2% 7 53.8% University of Limerick Hospital Group Total 19 2 10.5% 17 89.5% Croom Hospital, Limerick 1 0 0.0% 1 100.0% University Maternity Hospital, Limerick 1 0 0.0% 1 100.0% University Hospital, Limerick 13 2 15.4% 11 84.6% Ennis Hospital 2 0 0.0% 2 100.0% Nenagh Hospital 1 0 0.0% 1 100.0% St. John’s Hospital Limerick 1 0 0.0% 1 100.0% Continued. *% of total vending machines (N).

Table 10 continued. Proportion of vending machines meeting the ratio 60:40 of ‘Better Choice’ and ‘Other Choice’ products at site and by Hospital Group/CHO/National/Corporate and Other Services level based on nutritional information provided by vending companies Site Name Number of machines Machines meeting policy Machines not meeting policy N n % n % CHO 1 Total 10 3 25.0% 7 75.0% HSE Cregg Services Sligo 1 0 0.0% 1 100.0% Killybegs Community Hospital 1 0 0.0% 1 100.0% Our Lady's Hospital, Leitrim 2 1 50.0% 1 50.0% St. Davnett’s Primary Care 1 1 100.0% 0 0.0% 1 0 0.0% 1 100.0%

St. Joseph’s Hospital Donegal 1 0 0.0% 1 100.0% St. John's Community Hospital, Sligo 1 0 0.0% 1 100.0% Virginia Health Centre 1 0 0.0% 1 100.0% 1 1 100.0% 0 0.0%

CHO 2 Total 3 3 100.0% 0 0.0% Galway Training Centre 1 1 100.0% 0 0.0% Sacred Heart Hospital 2 2 100.0% 0 0.0% CHO 3 Total 3 0 0.0% 3 100.0% St. Camillus Hospital 2 0 0.0% 2 100.0% St. Joseph's Hospital Clare 1 0 0.0% 1 100.0% Continued.

Table 10 continued Proportion of vending machines meeting the ratio 60:40 of ‘Better Choice’ and ‘Other Choice’ products at site and by Hospital Group/CHO/National/Corporate and Other Services level based on nutritional information provided by vending companies Site Name Number of machines Machines meeting policy Machines not meeting policy N n % n % CHO 4 Total 6 4 66.7% 2 33.3% St. Columbanus 2 2 100.0% 0 0.0% St. Stephen's Hospital 1 1 100.0% 0 0.0% St. Finbarr's Hospital 1 1 100.0% 0 0.0% St. Patrick's Hospital, Cork 2 0 0.0% 2 100.0% CHO 5 Total 9 0 0.0% 9 100.0% Dungarvan Community Hospital 2 0 0.0% 2 100.0% Health Service Executive, Lacken 1 0 0.0% 1 100.0% HSE St Canice's Hospital 1 0 0.0% 1 100.0% HSE St Columba's Hospital 1 0 0.0% 1 100.0% St Johns Community Hospital, Wexford 2 0 0.0% 2 100.0% St. Luke's Department of Psychiatry, Kilkenny 2 0 0.0% 2 100.0% CHO 6 Total 3 1 33.3% 2 66.7% Clonskeagh Hospital 1 0 0.0% 1 100.0% Newcastle Hospital Wicklow 1 1 100.0% 0 0.0% 1 0 0.0% 1 100.0%

Continued.

HSE Maynooth Community Care Centre 1 0 0.0% 1 100.0% Peamount Hospital Newcastle 1 0 0.0% 1 100.0% St. Vincent's Hospital, Athy 2 1 50.0% 1 50.0% CHO 8 Total 8 1 14.3% 7 85.7% Department of Psychiatry, Louth 2 0 0.0% 2 100.0% HSE Beaufort House 1 0 0.0% 1 100.0% St. Brigid's Hospital 1 0 0.0% 1 100.0% St. Joseph's Care Centre, Longford 1 0 0.0% 1 100.0% St. Joseph's Hospital, Trim 1 0 0.0% 1 100.0% St. Mary's Hospital, Drogheda 1 1 100.0% 0 0.0% St. Vincent's Hospital, Mountmellick 1 0 0.0% 1 100.0%

CHO 9 Total 10 3 30.0% 7 70.0% HSE Administration Ballycoolin 1 0 0.0% 1 100.0% St. Ita’s Hospital Dublin 1 0 0.0% 1 100.0% St. Vincent's Hospital, Richmond Road, Dublin 1 1 100.0% 0 0.0% HSE Medical Records Longford 1 0 0.0% 1 100.0% St. Mary's Hospital, Dublin 6 2 33.3% 4 66.7%

Continued.

Table 10 continued. Proportion of vending machines meeting the ratio 60:40 of ‘Better Choice’ and ‘Other Choice’ products at site and by Hospital Group/CHO/National/Corporate and Other Services level based on nutritional information provided by vending companies Site Name Number of machines Machines meeting policy Machines not meeting policy N n % n % Health Business Services Total 5 0 0.0% 5 100.0% Dr. Steeven’s Hospital 1 0 0.0% 1 100.0% HSE Estate Office Swords 1 0 0.0% 1 100.0% HSE Estates Office 1 0 0.0% 1 100.0% HSE Park Gate Street 1 0 0.0% 1 100.0% HSE Procurement 1 0 0.0% 1 100.0% National Ambulance Services Total 2 1 50.0% 1 50.0% HSE National Ambulance Service 1 0 0.0% 1 100.0% Tullamore Ambulance Service 1 1 100.0% 0 0.0%

Primary Care Services Total 3 0 0.0% 3 100.0% HSE Primary Care Service Fingal 3 0 0.0% 3 100.0% Other Total 3 2 50.0% 1 50.0% Central Mental Hospital, Dundrum 1 0 0.0% 1 100.0% St. Vincent’s Daughters of Charity, Limerick 2 2 100.0% 0 0.0%

*Data displayed as number of machines (n) and % of total machines

1.3 Beverage sales

Sales of ‘Better Choice’ beverages accounted for 65% of total beverage unit sales in 2016 (Figure 6). At hospital group/CHO level (Table 11), this Figure ranged from 29% (CHO 2) to 75% (CHO 5). These findings are reflective of the higher availability of beverages that meet the ‘Better Choice’ criteria, compared to the lower availability of ‘Better Choice’ food products.

35%

65%

Better Choice Other Choice

Figure 6 ‘Better Choice’ and ‘Other Choice’ beverage unit sales at HSE level (2016). Beverages that met the ‘Better Choice’ criteria fell under 3 broad categories: water, fruit juice, and diet soft drinks. Beverages in the water category were further subcategorised into 3 groups: still water, sparkling water and flavoured water.

Diet soft drinks sales accounted for the majority of ‘Better Choice’ beverage sales in 2016 (54%) (Figure 7). Total water sales accounted for 37% of ‘Better Choice’ beverages sales: still water (28%), flavoured water (6%) and sparkling water (3%). 9% of ‘Better Choice’ beverage sales were attributable to fruit juice sales. These Figures varied greatly between sites (Table 12): water sales ranged from 0% to 67% of total ‘Better Choice’ beverage sales, diet soft drink sales ranged from 21% to 100% and fruit juice between 0% and 29%.

Sales of ‘Other Choice’ beverages (35%) were entirely attributable to non-diet soft drink sales.

28%

54% 3%

Still water Sparkling water Flavoured water Fruit juice Diet soft drinks

Figure 7. ‘Better Choice’ beverages sold at HSE level (2016) by beverage category

Table 11. Beverage units sold at Hospital Group/CHO/National/Corporate and other Services level during 2016 by beverage category. Site Name Total Beverage Units ‘Better Choice’ Beverages ‘Other Choice’ Beverages* (N) (n) % (n) %

Children's Hospital Group Total 64,719 36,881 57.0% 27,838 43.0% Temple Street Hospital 64,719 36,881 57.0% 27,838 43.0%

Dublin Midlands Hospital Group Total 78,171 52,071 66.6% 26,100 33.4% Midland Regional Hospital, Portlaoise 13,693 9,393 68.6% 4,300 31.4% Naas General Hospital 33,706 23,012 68.3% 10,694 31.7% St. Luke’s Hospital Rathgar 10,897 7,385 67.8% 3,512 32.2% St. Luke’s James Street 539 437 81.1% 102 18.9% St. Luke’s Radiation Beaumont 543 355 65.4% 188 34.6% Tallaght Hospital, Dublin 1,354 1,002 74.0% 352 26.0% Midland Regional Hospital, Tullamore 17,439 10,487 60.1% 6,952 39.9% Continued *All ‘Other Choice’ beverages are non-diet soft drinks. Data displayed as number of beverage units sold (n) and % of total beverages sold.

Ireland East Hospital Group Total 112,620 77,949 68.2% 34,671 31.8% Cappagh National Orthopaedic Hospital, 1,009 635 62.9% 374 37.1% Dublin Ely Hospital, Wexford 941 702 74.6% 239 25.4% Midland Regional Hospital, Mullingar 16,346 11,099 67.9% 5,247 32.1% Our Lady’s Hospital, Meath 1,962 1,458 74.3% 504 25.7% 4,462 2,657 59.5% 1,805 40.5%

Royal Victoria Eye & Ear Hospital, Dublin 17,553 12,358 70.4% 5,195 29.6% St. Luke’s Hospital Kilkenny 22,027 15,434 70.1% 6,593 29.9% St. Michael’s Hospital, Dún Laoighre 3,408 2,282 67.0% 1,126 33.0% St. Vincent’s University Hospital, Dublin 12,159 8,303 68.3% 3,856 31.7% Wexford General Hospital 34,755 23,021 66.2% 11,734 33.8% RCSI Hospital Group Total 136,471 94,089 68.9% 42,382 31.1% Beaumont Hospital, Dublin 65,371 45,293 69.3% 20,078 30.7% Cavan General Hospital 22,201 14,955 67.4% 7,246 32.6% Louth County Hospital, Dundalk 2,716 1,796 66.1% 920 33.9% Monaghan Hospital 1,403 1,188 84.7% 215 15.3% Our Lady of Lourdes Hospital, Drogheda 36,457 25,899 71.0% 10,558 29.0% Rotunda Hospital, Dublin 8,323 4,958 59.6% 3,365 40.4% Saolta Hospital Group Total 38,319 21,938 57.3% 16,381 42.7% Letterkenny General Hospital 6,700 4,095 61.1% 2,605 38.9% Sligo General Hospital 31,619 17,843 56.4% 13,776 43.6% Continued.

Table 11 continued. Beverage units sold at Hospital Group/CHO/National/Corporate and other Services level during 2016 by beverage category. ‘Better Choice’ Beverages Site Name Total Beverage Units ‘Other Choice’ Beverages*

(N) (n) % (n) %

South/South West Hospital Group Total 170,192 106,944 62.8% 63,248 37.2% Bantry General Hospital 3,324 1,829 55.0% 1,495 45.0% Cork University Hospital 67,520 46,516 68.9% 21,004 31.1% Lourdes Orthopaedic Hospital, Kilcreene 1,949 1,315 66.6% 634 33.4% Mallow General Hospital 3,209 1,977 61.6% 1,232 38.4% Mercy University Hospital 16,983 7,487 44.1% 9,496 55.9% South Infirmary Victoria University Hospital 8,903 5,943 66.8% 2,960 33.2% South Tipperary General Hospital 20,022 12,382 61.8% 7,640 38.2% University Hospital Kerry, Tralee 32,518 17,810 54.8% 14,708 45.2% University Hospital Waterford 15,764 11,685 74.1% 4,079 25.9% University of Limerick Hospital Group Total 91,859 56,131 61.1% 35,728 38.9% Croom Hospital, Limerick 1,651 1,474 89.3% 177 10.7% University Maternity Hospital, Limerick 4,304 2,606 60.5% 1,698 39.5% University Hospital, Limerick 61,849 41,717 67.4% 20,132 32.6% Ennis Hospital 9,291 6,358 68.4% 2,933 31.6% Nenagh Hospital 14,410 3,716 25.8% 10,694 74.2% St. John’s Hospital Limerick 354 260 73.4% 94 26.6% Continued. *All ‘Other Choice’ beverages are non-diet soft drinks. Data displayed as number of beverage units sold (n) and % of total beverages sold.

CHO 1 Total 9,639 5,713 59.3% 3,937 40.7% HSE Cregg Services Sligo 835 511 61.2% 324 38.8% Killybeg’s Community Hospital 681 486 71.4% 195 28.6% Our Lady’s Hospital, Leitrim 988 575 58.2% 413 41.8% St. Davnett’s Primary Care 784 470 59.9% 314 40.1% 533 208 39.0% 325 61.0% St. Joseph’s Hospital, Donegal 4,126 2,175 52.7% 1,951 47.3% St. John's Community Hospital, Sligo 394 394 100.0% 0 0.0% Virginia Health Care Centre 227 60 26.4% 167 73.6% 1,082 834 77.1% 248 22.9%

CHO 2 Total 4,594 1,334 29.0% 3,260 71.0% Galway Training Centre 3,174 495 15.6% 2,679 84.4% Sacred Heart Hospital 1,420 839 59.1% 581 40.9% CHO 3 Total 5,619 4,022 71.6% 1,597 28.4% St. Camillus Hospital 4,836 3,442 71.2% 1,394 28.8% St. Joseph’s Hospital, Clare 783 580 74.1% 203 25.9%

CHO 4 Total 4,023 2,404 59.8% 1,619 40.2% St. Columbanus 306 157 51.3% 149 48.7% St. Finbarr’s Hospital 176 100 56.8% 76 43.2% St. Patrick’s Hospital, Cork 2,466 1,810 73.4% 656 26.6% St. Stephen’s Hospital 1,075 337 31.3% 738 68.7%

Continued. *All ‘Other Choice’ beverages are non-diet soft drinks. Data displayed as number of beverage units sold (n) and % of total beverages sold.

Table 11 continued. Beverage units sold at Hospital Group/CHO/National/Corporate and other Services level during 2016 by beverage category.

Site Name Total Beverage Units ‘Better Choice’ Beverages ‘Other Choice’ Beverages* (N) (n) % (n) %

CHO 5 Total 10,986 8,106 67.4% 2,880 32.6% Dungarvan Community Hospital 3,909 2,835 72.5% 1,074 27.5% Health Service Executive, Lacken 370 292 78.9% 78 21.1% St. Canice's Hospital 1,117 904 80.9% 213 19.1% St. Columba's Hospital 804 607 75.5% 197 24.5% St. John’s Community Hospital, Wexford 3,161 1,843 58.3% 1,318 41.7% St. Luke’s Department of Psychiatry, Kilkenny 1,625 1,625 100% 0 0.0%

CHO 6 Total 3,560 2,461 69.1% 1,099 30.9% Clonskeagh Hospital 1,841 1,296 70.4% 545 29.6% Newcastle Hospital, Wicklow 834 460 55.2% 374 44.8% 885 705 79.7% 180 20.3%

Continued. *All ‘Other Choice’ beverages are non-diet soft drinks. Data displayed as number of beverage units sold (n) and % of total beverages sold.

Table 11 continued. Beverage units sold at Hospital Group/CHO/National/Corporate and other Services level during 2016 by beverage category. Site Name Total Beverage Units ‘Better Choice’ Beverages ‘Other Choice’ Beverages* (N) (n) % (n) % CHO 7 Total 8,257 5,117 62.0% 3,140 38.0% Baltinglass Hospital 1,019 559 54.9% 460 45.1% Cherry Orchard Hospital 583 312 53.5% 271 46.5% 3,118 1,857 59.6% 1,261 40.4%

HSE Maynooth Community Care Ct 905 604 66.7% 301 33.3% Peamount Hospital, Newcastle 823 539 65.5% 284 34.5% St. Vincent’s Hospital, Athy 1,809 1,246 68.9% 563 31.1%

CHO 8 Total 11,071 6,184 55.9% 4,887 44.1% Department of Psychiatry, Louth 1,500 1,195 79.7% 305 20.3% HSE Beaufort House 2,518 359 14.3% 2,159 85.7% St. Brigid’s Hospital 1,465 683 46.6% 782 53.4% St. Joseph’s Care Centre, Longford 958 633 66.1% 325 33.9% St. Joseph’s Hospital Trim 1,411 1,218 86.3% 193 13.7% St. Mary’s Hospital, Drogheda 655 369 56.3% 286 43.7% St. Vincent’s Hospital, Mountmellick 2,564 1,727 67.4% 837 32.6% Continued. *All ‘Other Choice’ beverages are non-diet soft drinks. Data displayed as number of beverage units sold (n) and % of total beverages sold.

Table 11 continued. Beverage units sold at Hospital Group/CHO/National/Corporate and other Services level during 2016 by beverage category. Site Name Total Beverage Units (N) ‘Better Choice’ Beverages (n) ‘Other Choice’ Beverages*(n)

CHO 9 Total 15,193 10,003 65.8% 5,190 34.2%

HSE Administration Ballycoolin 594 447 75.3% 147 24.7% HSE Medical Records Longford 0 0 0 0 0 St. Ita’s Hospital Dublin 2,570 1,342 52.2% 1,228 47.8% St. Mary’s Hospital, Dublin 7,431 4,332 58.3% 3,099 41.7%

St. Vincent’s Hospital, Richmond Road, Dublin 4,598 3,882 84.4% 716 15.6%

Health Business Services Total 8,247 5,367 65.1% 2,880 34.9%

Dr. Steeven’s Hospital 1,038 682 65.7% 356 34.3% HSE Estate Office Swords 728 533 73.2% 195 26.8% HSE Estates Office 316 190 60.1% 126 39.9%

HSE Park Gate Street 3,367 2,083 61.9% 1,284 38.1% HSE Procurement 2,798 1,879 67.2% 919 32.8%

National Ambulance Services Total 3,296 2,302 69.8% 994 30.2%

HSE National Ambulance Service 2,950 2,199 74.5% 751 25.5% Tullamore Hospital Ambulance 346 103 29.8% 243 70.2%

Primary Care Services Total 19,117 11,796 61.7% 7,321 38.3% HSE Primary Care Service Fingal 19,117 11,796 61.7% 7,321 38.3%

Other Total 2,121 2,168 73.5% 561 25.6% Central Mental Hospital, Dundrum 2,121 1,560 73.6% 561 26.4%

St. Vincent’s Daughters of Charity, Limerick 1,289 608 47.1% 681 52.9%

HSE Total 798,074 512,980 64.3% 285,713 35.8%

*All ‘Other Choice’ beverages are non-diet soft drinks. Data displayed as number of beverage units sold (n) and % of total beverages sold.

Table 12. Better Choice beverage units sold at Hospital Group/CHO and National/Corporate and other Services level during 2016 by beverage category.

Site Name Water (all) Still water Sparkling water Flavoured water Fruit juice Diet soft drinks

(N) % (n) % (n) % (n) % (N) % (N) %

Children's Hospital Group Total 17,818 48.3% 17,818 48.3% 0 0.0% 0 0.0% 230 0.6% 18,833 51.1% Temple Street Hospital 17,818 48.3% 17,818 48.3% 0 0.0% 0 0.0% 230 0.6% 18,833 51.1%

Dublin Midlands Hospital Group Total 18,281 35.1% 13,307 25.6% 2,046 3.9% 2,928 5.6% 4,208 8.1% 29,582 56.8% Midland Regional Hospital, Portlaoise 3,767 40.1% 2,564 27.3% 541 5.8% 662 7.0% 865 9.2% 4,761 50.7% Naas General Hospital 8,330 36.2% 5,348 23.2% 1,111 4.8% 1,871 8.1% 2,235 9.7% 12,447 54.1% St. Luke’s Hospital Rathgar 2,103 28.5% 1,464 19.8% 309 4.2% 330 4.5% 680 9.2% 4,602 62.3% St. Luke’s James Street 168 38.4% 64 14.6% 65 14.9% 39 8.9% 45 10.3% 224 51.3% St. Luke’s Radiation Beaumont 145 40.8% 99 27.9% 20 5.6% 26 7.3% 37 10.4% 173 48.7% Tallaght Hospital, Dublin 397 39.6% 397 39.6% 0 0.0% 0 0.0% 0 0.0% 605 60.4% Midland Regional Hospital, Tullamore 3,371 32.1% 3,371 32.1% 0 0.0% 0 0.0% 346 3.3% 6,770 64.6%

Ireland East Hospital Group Total 35,103 45.03% 25,267 32.41% 3,668 4.71% 6,168 7.91% 7,662 9.82% 35,184 45.13% Cappagh National Orthopaedic Hospital, 179 28.20% 106 16.70% 25 3.90% 48 7.60% 151 23.80% 305 48.00% Dublin Ely Hospital, Wexford 272 38.70% 158 22.50% 55 7.80% 59 8.40% 28 4.00% 402 57.30% Midland Regional Hospital, Mullingar 5,097 45.90% 4,029 36.30% 321 2.90% 747 6.70% 1,019 9.20% 4,983 44.90% Our Lady’s Hospital Meath 160 11.00% 60 4.10% 35 2.40% 65 4.50% 130 8.90% 1,168 80.10% 153 5.75% 153 5.75% 0 0.00% 0 0.00% 86 3.23% 2,418 91.00% Royal Victoria Eye & Ear Hospital, 5,871 47.50% 3,811 30.80% 833 6.70% 1,227 9.90% 1,070 8.70% 5,417 43.80% Dublin St. Luke’s Hospital, Kilkenny 8,191 19.90% 6,262 15.40% 649 1.80% 1,280 2.70% 1,766 29.40% 5,477 48.00% St. Michael’s Hospital, Dún Laoghaire 793 34.80% 522 22.90% 163 7.10% 108 4.70% 261 11.40% 1,228 53.80% St. Vincent’s University Hospital, Dublin 3,149 37.90% 2,225 26.80% 415 5.00% 509 6.10% 703 8.50% 4,451 53.60% Wexford General Hospital 11,238 48.80% 7,941 34.50% 1,172 5.10% 2,125 9.20% 2,448 10.60% 9,335 40.50%

Continued.

Table 12 continued. Better Choice beverage units sold at Hospital Group/CHO and National/Corporate and other Services level during 2016 by beverage category.

Site Name Water (all) Still water Sparkling water Flavoured water Fruit juice Diet soft drinks

(N) % (n) % (n) % (n) % (N) % (N) %

RCSI Hospital Group Total 37,805 40.2% 27,588 29.3% 3,724 4.0% 6,493 6.9% 10,101 10.7% 46,183 49.1%

Beaumont Hospital 19,439 42.9% 14,766 32.6% 1,948 4.6% 2,725 6.0% 4,537 10.0% 21,317 47.1% Cavan General Hospital 5,012 33.5% 2,837 19.0% 664 4.4% 1,511 10.1% 1,162 7.8% 8,781 58.7% Louth County Hospital, Dundalk 381 21.2% 260 14.5% 45 2.5% 76 4.2% 207 11.5% 1,208 67.3% Monaghan Hospital 616 51.9% 524 44.1% 43 3.6% 49 4.1% 134 11.3% 438 36.9% Our Lady of Lourdes Hospital, 10,513 40.6% 7,656 29.6% 911 3.5% 1,946 7.5% 3,656 14.1% 11,730 45.3% Drogheda Rotunda Hospital Dublin 1,844 37.2% 1,545 31.2% 113 2.3% 186 3.8% 405 8.2% 2,709 54.6%

Saolta Hospital Group Total 5,523 25.2% 3,780 17.2% 740 3.4% 1,003 4.6% 2,349 10.7% 14,066 64.1%

Letterkenny General Hospital 0 0.0% 0 0.0% 0 0.0% 0 0.0% 551 13.5% 3,544 86.5% Sligo General Hospital 5,523 31.0% 3,780 21.2% 740 4.1% 1,003 5.6% 1,798 10.1% 10,522 59.0% South/South West Hospital 37,295 34.9% 30,988 29.0% 2,158 2.0% 4,149 3.9% 7,464 7.0% 62,185 58.1% Group Total Bantry General Hospital 632 34.60% 632 34.60% 0 0.00% 0 0.00% 79 4.30% 1,118 61.10% Cork University Hospital 16,302 35.00% 10,707 23.00% 2,102 4.50% 3,493 7.50% 3,584 7.70% 26,630 57.20% Lourdes Orthopaedic Hospital, 483 36.7% 356 27.1% 56 4.3% 71 5.4% 162 12.30% 670 51.0% Kilcreene Mallow General Hospital 468 23.70% 468 23.70% 0 0.00% 0 0.00% 251 12.70% 1,258 63.60% Mercy University Hospital 3,139 41.90% 3,139 41.90% 0 0.00% 0 0.00% 132 1.80% 4,216 56.30% South Infirmary University Hospital 1,465 24.70% 1,465 24.70% 0 0.00% 0 0.00% 178 3.00% 4,300 72.40% South Tipperary General Hospital 5,096 41.20% 4,868 39.30% 0 0.00% 228 1.80% 1,461 11.80% 5,825 47.00% University Hospital Kerry, Tralee 6,231 35.0% 6,231 35.0% 0 0.00% 0 0.00% 468 2.62% 11,111 62.40% University Hospital Waterford 3,479 29.80% 3,122 26.70% 0 0.00% 357 3.10% 1,149 9.80% 7,057 60.40%

Continued.

Table 12 continued. Better Choice beverage units sold at Hospital Group/CHO and National/Corporate and other Services level during 2016 by beverage category.

Site Name Water (all) Still water Sparkling water Flavoured water Fruit juice Diet soft drinks

(N) % (n) % (n) % (n) % (N) % (N) % University of Limerick Hospital 20,256 36.1% 14,609 26.0% 2,227 4.0% 3,420 6.1% 5,679 10.1% 30,196 53.8% Group Total Croom Hospital Limerick 870 59.0% 598 40.6% 115 7.8% 157 10.7% 83 5.6% 521 35.3% University Maternity Hospital, 361 13.9% 171 6.6% 16 0.6% 174 6.7% 286 11.0% 1,959 75.2% Limerick University Hospital Limerick 15,017 36.0% 10,390 24.9% 1,948 4.7% 2,679 6.4% 4,055 9.7% 22,645 54.3% Ennis Hospital 1,991 31.3% 1,674 26.3% 126 2.0% 191 3.0% 844 13.3% 3,523 55.4% Nenagh Hospital 1,941 52.2% 1,731 46.6% 15 0.4% 195 5.2% 399 10.7% 1,376 37.0% St. John’s Hospital Limerick 76 29.2% 45 17.3% 7 2.7% 24 9.2% 12 4.6% 172 66.2%

CHO 1 Total 1,385 24.2% 892 15.6% 189 3.3% 304 5.3% 513 9.0% 3,815 66.8% HSE Cregg Services Sligo 226 44.2% 95 18.6% 30 5.9% 101 19.8% 71 13.9% 214 41.9% Killybeg’s Community Hospital 194 39.9% 136 28.0% 11 2.3% 47 9.7% 33 6.8% 259 53.3% Our Lady’s Hospital, Leitrim 109 19.0% 109 19.0% 0 0.0% 0 0.0% 0 0.0% 466 81.0% St Davnetts Primary Care 14 6.7% 14 6.7% 0 0.0% 0 0.0% 0 0.0% 194 93.3% 139 29.6% 74 15.7% 18 3.8% 47 10.0% 93 19.8% 238 50.6% St. Joseph’s Hospital, Donegal 126 5.8% 101 4.6% 10 0.5% 15 0.7% 202 9.3% 1,847 84.9% St. John's Community Hospital, 53 13.5% 19 4.8% 18 4.6% 16 4.1% 28 7.1% 313 79.4% Sligo Virginia Health Care Centre 1 1.7% 1 1.7% 0 0.0% 0 0.0% 0 0.0% 59 98.3% 523 62.7% 343 41.1% 102 12.2% 78 9.4% 86 10.3% 225 27.0%

CHO 2 Total 382 28.6% 382 28.6% 0 0.0% 0 0.0% 180 13.5% 772 57.9% Galway Training Centre 58 11.7% 58 11.7% 0 0.0% 0 0.0% 0 0.0% 437 88.3% Sacred Heart Hospital 324 38.6% 324 38.6% 0 0.0% 0 0.0% 180 21.5% 335 39.9%

Continued.

Table 12 continued. Better Choice beverage units sold at Hospital Group/CHO and National/Corporate and other Services level during 2016 by beverage category.

Site Name Water (all) Still water Sparkling water Flavoured water Fruit juice Diet soft drinks

(N) % (n) % (n) % (n) % (N) % (N) %

CHO 3 Total 1,597 39.7% 1,124 27.9% 146 3.6% 327 8.1% 552 13.7% 1,873 46.6% St. Camillus Hospital 1,334 38.8% 931 27.0% 106 3.1% 297 8.6% 492 14.3% 1,616 46.9% St. Joseph’s Hospital, Clare 263 45.3% 193 33.3% 40 6.9% 30 5.2% 60 10.3% 257 44.3%

CHO 4 Total 791 32.9% 578 24.0% 86 3.6% 127 5.3% 209 8.7% 1,404 58.4%

St. Columbanus 24 15.3% 24 15.3% 0 0.0% 0 0.0% 0 0.0% 133 84.7% St. Finbarr’s Hospital 34 34.0% 34 34.0% 0 0.0% 0 0.0% 0 0.0% 66 66.0% St. Patrick’s Hospital, Cork 733 40.5% 520 28.7% 86 4.8% 127 7.0% 209 11.5% 868 48.0% St. Stephen’s Hospital 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 337 100.0%

CHO 5 Total 1,873 23.11% 1,216 15.00% 286 3.53% 371 4.58% 2,109 26.02% 4,124 50.88%

Dungarvan Community Hospital 831 29.30% 529 18.70% 139 4.90% 163 5.70% 236 8.30% 1,768 62.40%

Health Service Executive, Lacken 34 11.60% 34 11.60% 0 0.00% 0 0.00% 0 0.00% 258 88.40% St. Canice's Hospital 138 15.30% 85 9.40% 33 3.70% 20 2.20% 55 6.10% 711 78.70% St. Columba's Hospital 146 24.10% 65 10.70% 10 1.60% 71 11.70% 27 4.40% 434 71.50% St. John’s Community Hospital, 724 39.30% 503 27.30% 104 5.60% 117 6.30% 166 9.00% 953 51.70% Wexford St. Luke’s Department of 0 0.00% 0 0.00% 0 0.00% 0 0.00% 1,625 100.00% 0 0.00% Psychiatry, Kilkenny CHO 6 Total 593 24.1% 331 13.5% 103 4.2% 159 6.5% 142 5.8% 1,726 70.1%

Clonskeagh Hospital 461 35.6% 266 20.5% 57 4.4% 138 10.6% 98 7.6% 737 56.9% Newcastle Hospital, Wicklow 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 460 100.0% 132 18.7% 65 9.2% 46 6.5% 21 3.0% 44 6.2% 529 75.0%

Continued.

Table 12 continued. Better Choice beverage units sold at Hospital Group/CHO and National/Corporate and other Services level during 2016 by beverage category. Site Name Water (all) Still water Sparkling water Flavoured water Fruit Juice Diet

(N) % (n) % (n) % (n) % (N) % (N) %

CHO 7 Total 1,113 21.8% 904 17.7% 34 0.7% 175 3.4% 245 4.8% 3,759 73.5%

Baltinglass Hospital 192 34.3% 187 33.5% 0 0.0% 5 0.9% 0 0.0% 367 65.7%

Cherry Orchard Hospital 0 0.0% 0 0.0% 0 0.0% 0 0.0% 93 29.8% 219 70.2%

313 16.9% 313 16.9% 0 0.0% 0 0.0% 0 0.0% 1,544 83.1%

HSE Maynooth Community Care 164 27.2% 97 16.1% 19 3.1% 48 7.9% 34 5.6% 406 67.2% Centre Peamount Hospital, Newcastle 167 31.0% 101 18.7% 15 2.8% 51 9.5% 53 9.8% 319 59.2%

St. Vincent’s Hospital, Athy 277 22.2% 206 16.5% 0 0.0% 71 5.7% 65 5.2% 904 72.6%

CHO 8 Total 1,689 27.3% 1,016 16.4% 292 4.7% 381 6.2% 878 14.2% 3,617 58.5%

Department of Psychiatry, Louth 235 19.7% 114 9.5% 31 2.6% 90 7.5% 524 43.8% 436 36.5%

HSE Beaufort House 0 0.0% 0 0.0% 0 0.0% 0 0.0% 108 30.1% 251 69.9%

St. Brigid’s Hospital 138 20.2% 138 20.2% 0 0.0% 0 0.0% 0 0.0% 545 79.8%

St. Joseph’s Care Centre, Longford 210 33.2% 123 19.4% 46 7.3% 41 6.5% 58 9.2% 365 57.7%

St. Joseph’s Hospital Trim 525 43.1% 325 26.7% 72 5.9% 128 10.5% 69 5.7% 624 51.2%

St. Mary’s Hospital, Drogheda 24 6.5% 24 6.5% 0 0.0% 0 0.0% 0 0.0% 345 93.5%

St. Vincent’s Hospital, Mountmellick 557 32.3% 292 16.9% 143 8.3% 122 7.1% 119 6.9% 1,051 60.9%

CHO 9 Total 1,760 17.6% 1,470 14.7% 65 0.6% 225 2.2% 466 4.7% 7,777 77.7%

HSE Administration Ballycoolin 187 41.8% 147 32.9% 20 4.5% 20 4.5% 22 4.9% 238 53.2%

HSE Medical Records Longford 0 0 0 0 0 0 0 0 0 0 0 0

St. Ita’s Hospital Dublin 472 35.2% 364 27.1% 45 3.4% 63 4.7% 173 12.9% 697 51.9%

St. Mary’s Hospital, Dublin 1,101 25.4% 959 22.1% 0 0.0% 142 3.3% 271 6.3% 2,960 68.3%

St. Vincent’s Hospital, Dublin 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 3,882 100.0%

Continued.

Table 12 continued. Better Choice beverage units sold at Hospital Group/CHO and National/Corporate and other Services level during 2016 by beverage category.

Site Name Water (all) Still water Sparkling water Flavoured water Fruit Juice Diet

(N) % (n) % (n) % (n) % (N) % (N) %

Health Business Services Total 825 15.4% 377 7.0% 256 4.8% 192 3.6% 162 3.0% 4,380 81.6%

Dr. Steeven’s Hospital 125 18.3% 0 0.0% 101 14.8% 24 3.5% 16 2.3% 541 79.3% HSE Estate Office Swords 223 41.8% 191 35.8% 18 3.4% 14 2.6% 17 3.2% 293 55.0% HSE Estates Office 52 27.4% 0 0.0% 0 0.0% 52 27.4% 11 5.8% 127 66.8% HSE Park Gate Street 129 6.2% 54 2.6% 64 3.1% 11 0.5% 5 0.2% 1,949 93.6% HSE Procurement 296 15.8% 132 7.0% 73 3.9% 91 4.8% 113 6.0% 1,470 78.2% National Ambulance Services 1,418 61.6% 811 35.2% 375 16.3% 232 10.1% 781 33.9% 103 4.5% Total HSE National Ambulance Service 1,418 64.5% 811 36.9% 375 17.1% 232 10.6% 781 35.5% 0 0.0% Tullamore Hospital Ambulance 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 103 100.0%

Primary Care Services Total 3,822 32.4% 3,331 28.2% 195 1.7% 296 2.5% 1,458 12.4% 6,516 55.2%

HSE Primary Care Service, Fingal 3,822 32.4% 3,331 28.2% 195 1.7% 296 2.5% 1,458 12.4% 6,516 55.2%

Other Group Total 719 33.2% 586 27.1% 81 3.7% 52 2.4% 227 10.5% 1,222 56.3%

Central Mental Hospital, Dundrum 657 42.1% 524 33.6% 81 5.2% 52 3.3% 227 14.6% 676 43.3% St. Vincent’s Daughters of Charity, 62 10.2% 62 10.2% 0 0.0% 0 0.0% 0 0.0% 546 89.8% Limerick HSE total 190,048 37.0% 146,375 28.5% 16,671 3.3% 27,002 5.3% 45,615 8.9% 277,317 54.1 %

Data displayed as number of units sold and % of total Better Choice beverages sold.

Discussion

Policy Implementation As described earlier, the implementation of the Policy is supported by HSE National Contract for Vending 2015-2020. The findings show that 89 health service sites transitioned to the companies on the framework in 2016. By 2017, this number has increased to 101 sites. However, there are 11 health service sites still on pre- existing contracts, contracts that are part of other catering contracts, contracts that have rolled over, sites that are not on contract with a vending company as they own their machines and self-fill and sites that have contracts with companies that are not on the framework. This contract variation poses a significant challenge in relation to compliance as it leads to inconsistencies and partial compliance rather than full compliance.

Compliance with the Policy The analyses verified that there was very good compliance in relation to calorie posting. 98% compliance with Better Choice products was reported (one out of fifty two Better Choice products exceeded the energy limit of ≤150kcals per packet) and 88% compliance with Other Choice products (eight out of sixty five Other Choice products exceeded the energy limit of ≤250kcals per packet).

However, the findings indicated that there was poorer compliance with the following criteria:

• the classification of Better Choice and Other Choice • the 60:40 ratio for Better Choice and Other Choice • product placement

Classification of products into Better Choice and Other Choice A total of 52 (22 snacks and 30 beverages) products were stocked by vending companies as ‘Better Choice’ products. Two thirds of those products met the policy criteria for ‘Better Choice’ products when categorised by the National Nutritional Surveillance Centre. On closer examination, it can be seen that all the beverages met the ‘Better Choice’ criteria whilst less than a fifth of food items met the ‘Better Choice’ criteria. The majority of Better Choice’ products that didn’t meet one of the nutrient criteria were at least 10% over the limit. Misclassification of products as ‘Better Choice’ leads to misinforming consumers and perhaps an unintentional consumption of less healthier options. This is counter to what we want to achieve with the policy, of increasing healthier options, and will need to be rectified.

Poor availability of Better Choice snack products in the market has been cited by the companies as a serious challenge since commencing healthier vending. In response to the companies’ request for sourcing Better Choice products, the Healthy Eating Active Living Programme examined 244 products that are available in the Irish and UK market and have found an additional 13 snack products that are Better Choice products that can be vended. They are mainly dried fruit which in the policy are exempt from fat and sugar criteria (Appendix 4).

60:40 ratio of Better Choice and Other Choice products Another criterion to meet in order to comply with the Healthier Vending policy is that machines must stock Better Choice and Other Choice products to a ratio of 60:40. In 2016, less than one third of all vending machines met this criterion across the health services. The drinks machines for both companies, were the only machine type that met the policy’s 60:40 ‘Better Choice’ to ‘Other Choice’ product ratio. In addition, since one in three Better Choice products were misclassified by the companies, the ratio of ‘Better Choice’ to ‘Other Choice’ would be lower in the other machine types, than those expressed in these results.

Product Placement A requirement of the Healthier Vending Policy is the placement of Better Choice products in prime slots in vending machines. Prime slots were defined as the rows in the vending machine at eye level, prompting products placed there to be chosen over products placed elsewhere in the machines. For one company, only the snacks machine met the product placement criteria and with the second company only the drink machines met the product placement criteria. It is important to note that the 60:40 ratio and product placement criteria are assessed by examining the standard planograms provided by the companies and has not been verified by a visual audit.

Commission generated A quarter of the total revenue generated at HSE level was returned as commission to health service sites. This passive income can act as an enticement for sites to have vending machines while at the same time it can undermine efforts to create a healthier food environment and promotion of staff health and wellbeing. While the income can be small in some sites, it can be valued as it is a flexible source of revenue for sites for meeting site needs at their discretion. The contribution of vending machines as a source of income needs to be balanced against the potential for negative impact on health and wellbeing of staff and visitors.

Beverage sales Sales of Better Choice beverages accounted for two thirds of total beverage unit sales in 2016. This is a positive finding, indicating that consumers are interested in purchasing Better Choice beverages when on offer.

Beverages that met the Better Choice criteria fell under 3 broad categories: water, fruit juice, and diet soft drinks. Beverages in the water category were further subcategorised into 3 groups: still water, sparkling water and flavoured water.

Diet soft drinks sales accounted for halfof Better Choice beverage sales in 2016. Total water sales accounted for one third of Better Choice beverage sales. Sales of Other Choice beverages were entirely attributable to non-diet soft drink sales. 54

A note on ‘milk and water’ as Better Choice items The policy was reviewed in 2015 and the following update was added: ‘Note: As of February 2016 in the interest of dental health; milk and water will be the only drinks that can be included in the “Better Choice” items.’ That update has not been enforced as yet. Also, the policy does not specify if water includes/excludes flavoured water or sparkling water.

A note on ‘diet soft drinks’ as Better Choice products

There has been some discussion about ‘diet soft drinks’ for example, diet coke, being classified as a Better Choice product as it can portray ‘diet soft drinks’ as being a healthy option. They are a healthier option than ‘non-diet soft drinks’ and meet the current calorie and nutrient criteria for the Better Choice classification. However implementing the provision re: milk and water on grounds of dental health will change this situation.

Methodological limitations The data analyses carried out by NNSC and presented in this report is based on the data submitted by the vending companies and using their classification of Better Choice and Other Choice products. We know from these analyses that the companies’ classifications do not fully meet the criteria of the policy. It cannot be ruled out that some discrepancies in the proportion of products that met or did not meet the criteria for either ‘Better Choice’ or ‘Other Choice’ between the companies and the NNSC could be explained by the use of different sources of information in terms of nutrient content or by the methodology used by the companies to calculate nutrient content. Nutrient content analyses are not totally accurate and a certain degree of variability cannot be precluded based on the source of information used such as product labels, websites, food composition tables.

However, we can still elicit the percentage of sites/machines that are meeting the requirements of the policy based on the company data. This percentage would be the same when using either the vending companies’ classification system or the NNSC classification system.

While data is analysed for calorie information, the 60:40 ratio requirement and product placement, it does not audit the machines physically to verify that the calorie posting is done accurately, that Better Choice products are placed in prime slots or that branding specifications are met.

The analyses on the products location in the machines and the 60:40 ratio were based on either standard planograms or a random sample of machines provided by the companies. Therefore, these analyses might not completely represent all the machines included in the analyses.

Conclusion

Obesity is recognised internationally and in Ireland as a major health concern. In Ireland, 62% of the population are overweight or obese. Being overweight or obese increases a person’s risk for developing a chronic disease. To address these issues, the HSE introduced the Healthier Vending Policy in 2014 as part of its work to create a healthier food environment.

The implementation of the Healthier Vending Policy is supported by a national procurement framework known as the HSE National Contract for Vending 2015-2020. Following a public procurement process two companies were appointed as suppliers under the Framework. The National Nutrition Surveillance Centre (NNSC), UCD was commissioned to undertake the analyses of data from the vending companies by the Healthy Eating Active Living Programme.

This report outlined the progress of implementation of the policy in relation to mapping health service sites with vending machines and identifying the contract arrangements. It also reported on the data analyses of 295 vending machines across 89 health service health service sites health service sites in 2016.

It is clear from the report that achieving compliance is complex and challenging for a variety of reasons. Despite having a National Contract for Vending since 2015, 9% of sites have not moved over to the new contracts. It is not clear, how challenging it will be to strengthen compliance of HSE funded agencies and further work is needed here. The low availability of Better Choice food products on the market is a constraint. In addition, the companies show low rates of compliance with the 60:40 ratio of ‘Better Choice’ to ‘Other Choice’ products and product placement. The policy will be reviewed in 2018 where the issues and recommendations of this report will be considered.

Recommendations

1. Discuss the findings of this report with vending companies on the framework and request to rectify misclassifications of products

2. HSE Health Business Services, Hospital Groups, Community Healthcare Organisations and other sites to work with the Healthy Eating Active Living Programme to identify next steps to improve compliance, with particular attention to the requirements in relation to HSE National Contract for Vending 2015- 2020 and the application of the policy to Section 38 and 39 funded agencies

i. The criteria that apply to Better Choice snack products – remove the nutrient profile criteria and apply a calorie ceiling to all snack products. ii. The provision that milk and water (excluding flavoured/carbonated water) are the only beverages classified and offered as Better Choice iii. Apply the existing nutrient profile criteria to Other Choice beverages iv. Revise the monitoring and audit roles and responsibilities to provide for: a. Annual compliance data collection, analyses and reporting at national level b. Appropriate local monitoring, including use of standard planograms for physical audits v. Extend the scope of the policy to address the availability of Better Choice and Other Choice snack products and beverages across the retail environment in health service sites. vi. Clarify the appropriate role for snack and beverage vending/sales in the provision of catering for staff and visitors in health service sites.

Appendices Appendix 1: Health service sites with vending machines Implementing Number of Healthier HSE AREA Site Contract/Supplier Vending Machines Vending Policy Beaumont Hospital 22 Framework Contract Yes Cavan General Hospital 4 Framework Contract Yes Monaghan Hospital 2 Framework Contract Yes RCSI Rotunda Hospital 7 Framework Contract Yes Hospital Connolly Hospital Group Blanchardstown 9 Framework Contract Yes 59 Our Lady of Lourdes Hospital Drogheda 14 Framework Contract Yes Louth County Hospital 1 Framework Contract Yes Total vending machines 59 100% 100% University Hospital Limerick 15 Framework Contract Yes University Maternity Hospital 4 Framework Contract Yes University of Limerick Ennis Hospital 3 Framework Contract Yes Hospital St John's Hospital, Limerick 1 Framework Contract Yes Group Nenagh Hospital 2 Framework Contract Yes 26 Croom Hospital, Limerick 1 Framework Contract Yes Total vending machines 26 100% 100% Cork University Hospital 15 Framework Contract Yes Cork University Maternity Hospital 3 Framework Contract Yes South/ Framework Contract South West Awaiting contract Hospital Mercy University Hospital 11 information Yes Group 76 South Infirmary Hospital 3 Framework Contract Yes Bantry General Hospital 4 Framework Contract Yes Mallow General Hospital 1 Framework Contract Yes

Tralee General Hospital 7 Framework Contract Yes

Framework Contract Partial

Awaiting contract implementat University Hospital Waterford 17 information ion

South Tipperary General Hospital 13 Framework Contract Yes Lourdes Orthopaedic Hospital, Kilcreene, Kilkenny 2 Framework Contract Yes Total vending machines 76 100% 90%

Implementing Number of Healthier HSE AREA Site Contract/Supplier Vending Machines Vending Policy St Luke’s Radiation Oncology Network 10 Framework Contract Yes Midland Regional Hospital, Portlaoise 5 Framework Contract Yes Midland Regional Hospital, Dublin Tullamore 10 Framework Contract Yes Midlands Naas General Hospital 10 Framework Contract Yes Hospital Group Tallaght Hospital 25 Framework Contract Yes 89 St James’ Hospital 27 Framework Contract Yes Not on contract Coombe Women and Infants Hospital owns machines University Hospital 2 and self-fills Partial Total vending machines 89 97% 97% Cappagh National Orthopaedic Hospital 5 Framework Contract Yes Framework Contract & St Vincent’s University Hospital 23 pre-dated contract (2) 92% Midland Regional Hospital, Mullingar 9 Framework Contract Yes St Michael's Hospital 2 Framework Contract Yes Ireland Our Lady’s Hospital, Navan 4 Framework Contract Yes East Royal Victoria Eye and Ear Hospital Hospital 3 Framework Contract Yes Group Wexford General Hospital 14 Framework Contract Yes 74 St. Luke's Hospital Kilkenny 4 Framework Contract Yes Partial, Not on contract Healthier Hospital owns machines options National Maternity Hospital 5 and self-fills introduced

Partial, In long term contract with stocks Mater Misericordiae University vending operator not on healthier Hospital 1 the framework. options

Pre-existing contract with Healthier company not on the options St. Columcille's Hospital 4 framework introduced Total vending machines 74 84% 84% Children's University Hospital Temple Street 10 Framework Contract Yes Our Lady's Children's Hospital Contract with company Children's Crumlin 8 not on the framework No Hospital Group National Children’s Hospital at Not 18 Tallaght Hospital 0 No vending machines applicable 18

Total vending machines 66.60% 66.60%

Implementing Number of Healthier HSE AREA Site Contract/Supplier Vending Machines Vending Policy

Letterkenny 7 Framework Contract Yes Sligo 10 Framework Contract Yes Pre-existing contract with company not on the University Hospital Galway 8 framework Partial Pre-existing contract with company not on the Saolta Merlin Park 3 framework Partial Hospital Pre-existing contract with Group company not on the 40 Mayo 8 framework Partial Pre-existing contract with company not on the Roscommon 1 framework No Pre-existing contract with company not on the Portiuncula 3 framework No Total vending machines 40 28.57% 28.57% Total Vending Machines HGs 382

Implementing Number of Healthier HSE AREA Site Contract/Supplier Vending Machines Vending Policy

Our Lady's Hospital, Leitrim 2 Framework Contract Yes St Davnett's Primary Care 2 Framework Contract Yes St John's Community Hospital 1 Framework Contract Yes CHO 1 HSE Cregg Services Sligo 1 Framework Contract Yes 9 Virginia Health Centre 1 Framework Contract Yes Killybegs Community Hospital 1 Framework Contract Yes St Patrick's Community Hospital 1 Framework Contract Yes Total vending machines 9 Sacred Heart Hospital 3 Framework Contract Yes Ballina District Hospital 1 Framework Contract Yes CHO 2 6 Galway Training Centre 1 Framework Contract Yes HSE Aras Attracta Mayo 1 Framework Contract Yes Total vending machines 6 Hospital of Assumption 1 Framework Contract Yes St Joseph's Hospital Clare 1 Framework Contract Yes CHO 3 St Camillus' Hospital 2 Framework Contract Yes 6 Raheen Community Hospital 1 Framework Contract Yes HSE Offices, Ballycummin Ave 1 Framework Contract Yes Total vending machines 6 CHO 4 8 St Columbanus 2 Framework Contract Yes

St Stephens' Hospital 2 Framework Contract Yes St Finbarr's Hospital 1 Framework Contract Yes St Patrick's Hospital 2 Framework Contract Yes

Farranlea Road Clinic 1 Framework Contract Yes

Total vending machines 8 CHO 5 HSE, Dublin Road, Lacken 1 Framework Contract Yes 10 St Johns Community Hospital 2 Framework Contract Yes Dungarvan Community Hospital 2 Framework Contract Yes HSE St Dympna's Carlow 1 Framework Contract Yes HSE St Columba's Hospital 1 Framework Contract Yes St Luke's Hospital Kilkenny 2 Framework Contract Yes HSE St Canice's Hospital 1 Framework Contract Yes Total vending machines 10 Newcastle Hospital 1 Framework Contract Yes Newcastle Hospital Wicklow 1 Framework Contract Yes CHO 6 Clonskeagh Hospital 1 Framework Contract Yes 3

Total vending machines 3 61

Implementing Number of Healthier HSE AREA Site Contract/Supplier Vending Machines Vending Policy

St Vincent's Hospital 2 Framework Contract Yes Baltinglass Hospital 1 Framework Contract Yes Peamount Hospital 1 Framework Contract Yes CHO 7 HSE Maynooth Community 7 Care Centre 1 Framework Contract Yes Cherry Orchard Hospital 1 Framework Contract Yes CAMHS Cherry Orchard Hospital 1 Framework Contract Yes Total vending machines 7 St Mary's Hospital 1 Framework Contract Yes Dept of Psychiatry 2 Framework Contract Yes St Brigid's Hospital 1 Framework Contract Yes St Joseph's Care Centre 1 Framework Contract Yes Birr Comm Nursing Home 1 Framework Contract Yes St Joseph's CNU 1 Framework Contract Yes Beaufort House, Navan CHO 8 Community Health Unit 1 Framework Contract Yes 12 St Vincent's Hospital 1 Framework Contract Yes Mental Health Day Hospital , Our Lady’s Hospital, Navan 1 Framework Contract Yes HSE Medical Records 1 Framework Contract Yes Tullamore Health Centre 1 Framework Contract Yes

Total vending machines 12 St Vincent's Hospital 1 Framework Contract Yes St Mary's Hospital 6 Framework Contract Yes HSE Administration Ballycoolin 1 Framework Contract Yes CHO 9 St Ita's Hospital, Portrane 1 Framework Contract Yes 9 Total vending machines 9

TOTAL VENDING MACHINES 70 ALL CHOs

Implementing Number of Healthier HSE AREA Site Contract/Supplier Vending Machines Vending Policy

HSE Estates Office, Unit 7,

Swords Business Campus 1 Framework Contract Yes HSE Estates Office, Holland HSE Road, National Technology National Park 1 Framework Contract Yes Corporate HSE Parkgate Street 1 Framework Contract Yes Others Dr Steevens' Hospital 1 Framework Contract Yes HSE National Ambulance

Service 1 Framework Contract Yes Ambulance, Tullamore General 15 Hospital, 2 Framework Contract Yes Central Mental Hospital 1 Framework Contract Yes HSE Primary Care Service

Fingal 3 Framework Contract Yes National Rehab Hospital 3 Framework Contract Yes Total vending machines 15

Total number of vending machines on Framework contracts and non-Framework contracts 2017 Framework Non Framework

Site contracts contracts Total Hospital Group 339 43 382 Total CHO 70 0 70 Total National, Corporate,

Other 15 0 15 Total vending machines 2017 424 (90.8%) 43 (9.2%) 467

Total number of sites on Framework contracts and non-Framework contracts 2017 Framework Non Framework

Site contracts contracts Total Hospital Group Sites 40 10 50 CHO sites 52 0 52 National, Corporate, Other

Sites 10 0 10 Total sites 102 (91%) 10 (9%) 112

Appendix 2: Scope of work for the National Nutrition Surveillance Centre (NNSC-UCD) to carry out to verify compliance with the Healthier Vending Policy.

This document outlines the scope of work the HSE has commissioned the National Nutrition Surveillance Centre (NNSC-UCD) to carry out to verify compliance with the Healthier Vending Policy. Purpose of the work: To gather and analyse data for 2016 from the HSE (including relevant data from the contracted vending service suppliers) for the National Contract for Vending 2015-2020, to monitor compliance with the policy and provide a baseline for monitoring changes in sales and consumption patterns from vending machines. Outputs: The results of the data analyses by NNSC should be provided to the HSE in an Excel workbook format with source data and summary tables per site and an overall 'whole of HSE' summary. Data analyses to be completed by mid October 2017.

The Healthy Eating Active Living programme will decide on the structure of the report and prepare a report per HG / CHO and overall HSE report.

The Healthy Eating Active Living programme will commission the NNSC to run the same analyses on data set for 2017 in first quarter of 2018.

The HSE intends to use the results of the data analyses to:

 monitor compliance at site level and national level with the components of the Healthier Vending Policy;  support General Managers at Hospital Group and CHO level to monitor and enforce compliance with the Healthier Vending Policy; and  inform the review process for the Healthier Vending policy.

Data analyses at site level should report on the following

 Number of machines per site / percentage of machines where product stock meets 60:40 criteria as defined by policy  Verify that individual products stocked as ‘better choice’ meet the criteria for the policy  Verify that ‘other choice products’ are within calorie limit of 250 calories.  Calculate the percentage of full revenue per site that comes from 'better choice' products  Calculate the total revenue from Vending Machines per site and the commission returned to site  Energy rating of machines per site - percentage of machines that are rated equal to/greater than A rating

Data analyses at organisation-wide level (HSE) Number of machines across the organisation supplied by Framework companies plus breakdown by company Percentage of machines across the organisation where product stock meets 60:40 criteria as defined by policy plus breakdown by company Percentage of revenue from all machines that comes from 'better choice' products Total revenue from Vending Machines across HSE – percentage of revenue returned. Review of machine planograms and verify that placement of ‘better choice’ product is in the ‘prime’ product placement slots.

Provide a list of products from product stocked across the companies that meet the ‘better choice’ criteria

Percentage of product stocked by companies as 'better choice' that: meets the criteria (150 calories plus nutrient profile) does not meet the criteria by virtue of one nutrient exceeding ceiling by 5% / 10% Beverages

 Percent of overall volume of beverage product sold that is water (broken out by still / sparkling / flavored)  Percent of overall volume of beverage product sold that fits within the description of ‘all soft drinks, energy drinks, sports drinks and fruit/vegetable drinks with added sugars (or sugar products)’

Appendix 3: Better Choice snack products that are available from UK and Irish market

Product Better Choice Snacks number 1 BEAR PUREFRUIT YOYO APPLE <20G> Dried Fruit 2 BEAR PUREFRUIT YOYO MANGO <20G> Dried Fruit 3 BEAR PUREFRUIT YOYO STRAW <20G> Dried Fruit 4 KELK KIDS RAISINS <294G> Dried Fruit 5 URBAN MANGO SNACK PK <35G> Dried Fruit 6 URBAN PINEAPPLE SNACK PK <35G> Dried Fruit 7 URBAN STRAWBERRY SNACK PK <35G> Dried Fruit 8 DE BRON WINE GUMS SUG FRE <100G> Dried Fruit

9 VER GF CRISPS SR CRMHERB <23G 24> www.veronicassnacks.ie 10 Marmite rice cakes (22g packet size) UK products 11 Slim Be cereal bars UK products Diablo no added sugar muesli bars (flavours lime; apricot; hazelnut; cranberry & raspberry- 12 NOT the yoghurt coated varieties) UK products 13 Yushoi Crispy snacks (21g bag, all flavours) UK products 14 Sesame Stick 30g 15 Tayto Treble Crunch Sweet Chilli 20g 16 Extra Mints 28g 17 Extra Peppermint Gum 39g

References

1. Department of Health (2013) Healthy Ireland: A Framework for Improved Health and Wellbeing 2013-2025, available at: http://health.gov.ie/blog/publications/healthy-ireland-a-framework-forimproved-health-and- wellbeing-2013-2025/

2. HSE ‘Healthy Ireland in the Health Services’ National implementation Plan 2015-2017 available at: https://www.hse.ie/eng/about/who/healthwellbeing/healthy-ireland/hidocs/hiimplementationplanweb.pdf

3. HSE Healthier Vending Policy (2014). Available at: https://www.hse.ie/eng/about/who/healthwellbeing/our- priority-programmes/heal/healthier-vending/

4. Department of Health (2017) Healthy Ireland Survey 2017. Summary of Findings. ISBN 978-1-4064-2965-7 http://health.gov.ie/wp-content/uploads/2017/10/16-048825-Healthy-Ireland-Survey-18-October_for- printing.pdf

5. safefood (2012) The Cost of Overweight and Obesity on the Island of Ireland, available at: http://www.safefood.eu/SafeFood/media/SafeFoodLibrary/Documents/Publications/Research%20Reports/Fina l-Exec-Summary-The-Economic-Cost-of-Obesity.pdf

6. Healthy Food for Life – the Healthy Eating Guidelines and Food Pyramid available at: http://www.healthyireland.ie/healthinitiatives/heg/Food%20Pyramid%20of%20the%20Food%20for%20Life%20 Programme

7. Department of Health (2016) A Healthy Weight for Ireland: Obesity Policy and Action Plan 2016 – 2025 available at: http://health.gov.ie/wp-content/uploads/2016/09/A-Healthy-Weight-for-Ireland-Obesity-Policy-and-Action-Plan- 2016-2025.pdf

8. Department of Health and Department of Transport, Tourism and Sport (2015) Get Ireland Active! National Physical Activity Plan for Ireland, Healthy Ireland, available at: http://health.gov.ie/wpcontent/uploads/2016/01/Get-Ireland-Active-the-National-Physical-Activity-Plan.pdf

9. HSE Calorie Posting Policy (2015). Available at: https://www.hse.ie/eng/about/who/healthwellbeing/our- priority-programmes/heal/calorie-posting/