Visit any Australian hospital two years ago and there was every chance you could buy any type of beverage you felt like – provided it wasn't booze or a decent coffee. Orange juice on the way to visit Aunty Sue in the orthopaedic ward? Sure. Red Bull while you're waiting to be seen in the emergency department? Done. Coke from the kiosk after an obesity clinic appointment? No problem, roll right up, would you like that in a can or bottle, love?
This is no longer the carbonated case.
In an effort to tackle obesity and dental problems, a growing number of Australian hospitals are restricting sugar-sweetened beverages such as Coke and Pepsi that health experts say have no nutritional value, just a whole lot of sugar.
"Overweight and obesity is associated with a wide range of chronic health conditions including type 2 diabetes, cardiovascular disease, stroke and some cancers," says Dr Jo Mitchell, executive director of the Centre for Population Health at NSW Health. "Eating too many unhealthy foods and not enough healthy foods is a major contributor to overweight and obesity."
Murrumbidgee Local Health District in NSW removed sugary soft drinks from the vending machines at all its facilities last year. Westmead Hospital in Sydney stopped selling sugar-sweetened beverages in March and Nepean Blue Mountains Local Health District followed suit by announcing it would also reduce the availability of unhealthy food and drinks on premises. And good luck finding anything but water and milk in the cafeterias of Victoria's Western District Health Service these days.
To be fair, Australia is playing catch up with New Zealand, which has had a government-enforced ban on the sale of sugar-sweetened drinks at healthcare sites since 2015. Head honchos at England's National Health Service are considering a similar move.
But what is interesting about Australia's hospital soft-drink restrictions, is that they are being implemented without enforced policy from a state or federal level. These are local health organisations that have had their fill of cola in the community.
The vital stats on fizz and fat
The Australian Bureau of Statistics found that in 2014-15, 63.4 per cent of Australian adults were overweight or obese. This a significant increase from 1995, when the figure was 56.3 per cent. About one in four children (27.4 per cent) aged five to 17 years were also found to be overweight or obese.
It's a pricey problem, too. A recent PricewaterhouseCoopers study estimated the cost of obesity in Australia in 2011-12 was $8.6 billion. When taking into account more "conceptual" wellbeing costs such as depression and discrimination, the figure is $47.4 billion.
"I couldn't sit by and watch this obesity epidemic – this crisis – unfold," says Rohan Fitzgerald, chief executive of Western District Health Service in the Southern Grampians Shire.
In December 2015, Fitzgerald's service became one of the first health organisations in Australia to implement soft-drink sale restrictions. Since then, 12 more health districts across Victoria's south-west have discontinued the sale of sugary drinks at their hospitals and facilities.
For a substantive solution to the obesity problem, most public health experts agree that a "sugar tax" on soft drinks is necessary. There also needs to be tighter restrictions on junk food marketing and better public education about the nutritional content of certain foods. Banning the sale of sugary drinks at hospitals is only one of many steps needed to combat the crisis. It is, however, an easier step than others.
Anna Peeters is the professor of epidemiology and equity in public health at Deakin University. She says there are two reasons for the focus on soft drink.
"First is the health impact. There's quite a lot of good evidence that sugary drinks are linked to weight gain, dental caries and diabetes. Secondly, sugar-sweetened soft drinks are a tangible target where there's no nutritional benefit but a lot of energy."
Westmead Hospital launched a three-month trial on March 1 to remove sugar-sweetened soft drinks from the hospital's vending machines and food outlets. It was the first trial of its kind for a major Sydney hospital.
"It's a beginning step," says Christine Newman, deputy director of population health at Western Sydney Local Health District. "We need to start nudging communities and their health services towards healthier food.
"We want to be absolutely clear that we're not about prohibiting or banning soft drink. If people choose to bring their own sugar-sweetened drinks into the hospital they certainly can. This is about sending a message to the community we don't think these drinks should be part of your diet and we, as a health service, should not have them sold on-site. We need to be a role model."
Why the sudden shake of the cola bottle?
Hospitals have long been an exemplar for health in the community. So why have sugary soft-drink restrictions gathered momentum only in the past 12 months?
Says Fitzgerald: "There is a big paradigm shift occurring from where we were five to 10 years ago, when health service chief executives were very much focused on 'the now', and maybe a few years into the future.
"Today, as a chief executive, I'm thinking more about the planning for decades into the future. How can I have an impact on what is a massive problem that currently exists?"
Fitzgerald was fortunate that Western District Health Service manages its own cafeterias and vending machines. Once the decision was made to restrict soft-drink sales, the service was able to implement the change almost immediately.
Many other Australian hospitals, including Westmead, are locked into contracts with soft-drink providers and external companies that manage on-site cafes. It's likely these companies are pretty keen on making a profit that selling only water and milk might not deliver.
"Working with our corporate services has been challenging, but I want to highlight that they have worked with us and have come on board," Newman says. "I haven't just said 'this is a new policy'. I've given them the same presentations we were giving to executives, explaining that we're doing this for the community's health."
Zouki is the external company that operates Westmead's cafe and many others in healthcare sites across Australia.
"I think Zouki is hearing that if you don't work with us, you're not going to be relevant in the future," Newman says. "Based on overseas case studies, we understand there is a dip in sales when these types of restrictions are implemented, but those sales eventually go back up on the healthier choices."
Natural fruit juice, flavoured milk and no-sugar soft drinks (which are still bad for your teeth, but preferable to the highly sugared stuff) are still available at Westmead.
"Going from a sugar-loaded carbonated beverage straight to water may not move people towards a healthier choice," Newman says. "They may just buy their sugar hit in another way. We're trying to move them onto other things first and then eventually water. It's a nudge process."
Getting the nudge
Is it actually a "nudge process", though? Or an example of nanny state-style meddling bureaucracy?
When Murrumbidgee Local Health District banned the on-site sale of sugary soft drinks in April 2016, NSW opposition health spokesman Walt Secord called to extend the restrictions across the state. Liberal Upper House MP Peter Phelps was reported to be "disgusted by Labor's policy" and described it as "yet another example of nanny state madness from out-of-touch elitists".
"Nanny state madness" becomes an irrelevant argument if change is initiated at a community level. And it's not only hospitals and schools revising their approach to soft drink.
In 2014, YMCA Victoria committed to eliminating the sale of sugary drinks at all its recreation centres, and the University of Sydney is assessing the feasibility of phasing out sugar-sweetened beverages after a proposal by the university community to restrict the sale and promotion of the drinks on campus. Advocacy network Parents' Voice is urging fast-food chains to offer water as the default drink option in children's meal deals. Subway Australia answered the call in early April and now only serves soft-drink in its kids' meals on request.
Victoria's Hamilton Basketball Association recently implemented "water-only" zones at games and training. The initiative forms part of a larger community movement in the Southern Grampians called "GenR8 Change". Western District Health Service is part of the program, too.
"It's about finding community actions that lead to fundamental change," Fitzgerald says. "This is where there's a paradigm shift from expecting policymakers to do absolutely everything, to talking to the community about how we can make substantive change that isn't specifically reliant on funding or policy directive. I think that's what's really exciting."
While this "bottom-up" movement is vital for long-term change, backup and policy will still be needed from federal and state governments to support healthy eating environments across Australia.
"At the moment in Australia, health issues like dental care and obesity are really unequally distributed," Peeters says.
"The rates are higher in disadvantaged groups, such as lower-income households and Indigenous Australians. If we don't have comprehensive multisetting approaches, we're not going to reach those groups. We might see overall trends improving, but we may not be improving the health of those who are the worst off."
The future for soft drink
The Australian Beverages Council is the peak body representing the interests of soft drink companies in Australia. The council does not agree that restricting the sale of sugar-sweetened beverages at healthcare sites is an effective method of addressing health concerns.
"Government data shows that the proportion of kilojoules consumed from sugar-sweetened beverages declined 15 per cent in adults and 40 per cent in children between 1995 and 2011, yet obesity rates rose dramatically over that period," says a spokesperson for the organisation.
"Across the population, soft drinks contribute less than 2 per cent of total daily kilojoule intake for adults and children. Further, soft drinks are ranked eighth and ninth in daily discretional or 'treat' kilojoules for adults and children respectively. Since sugar-sweetened beverages comprise such a small and declining part of the diet, it defies logic to assume that restricting sales in hospitals would be an effective method for tackling obesity."
Lawyer and research associate at The George Institute for Global Health, Alexandra Jones, says consumption data like this is difficult to verify, as people tend to under-report what they eat.
"Regardless of trends, Australians are consuming too much sugar, and rates of sugary drink consumption remain very high in both adults and kids," she says. "It's not only about the link to overweight and obesity; people of healthy weight should be concerned that regularly drinking sugary drinks will increase their risk of type 2 diabetes and tooth decay. These impacts start in our children.
"Obesity is complex, but we shouldn't let complexity get in the way of implementing promising policies."
If sugary beverage consumption continues to decline, there is still opportunity for drink companies to profit provided they're innovative with marketing and product design. Seventy-nine per cent of Coke's Australian brands, for example, now have a low or no sugar variety. (Although, it's also worth noting that only a third of Coca-Cola South Pacific's production volume comprises low kilojoule, zero kilojoule or no sugar drinks.)
"The goal is to make the healthy choices the easy choices and, over time, the preferred choices," Peeters says. "That requires innovation to understand what healthy food is convenient and how it fits into the settings people frequent every day. People need to like the healthy options and buy them."
Is there a possible future where every kid prefers to drink water instead of cola? Or eat apple slices instead of fries?
"I'm pretty optimistic we'll get there," Peeters says. "Five years ago I wasn't, but right now I am."