Healthy and Environmentally Sustainable Food Procurement and Foodservice in Australian Aged Care and Healthcare Services: A Scoping Review of ...
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sustainability
Review
Healthy and Environmentally Sustainable Food Procurement
and Foodservice in Australian Aged Care and Healthcare
Services: A Scoping Review of Current Research and Training
Lena D. Stephens , Judi Porter and Mark Lawrence *
Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University,
3220 Geelong, Australia; l.stephens@deakin.edu.au (L.D.S.); judi.porter@deakin.edu.au (J.P.)
* Correspondence: mark.lawrence@deakin.edu.au; Tel.: +61-3-924-43789
Abstract: Balancing the adoption of environmentally sustainable food systems in Australian health-
care and aged care settings whilst meeting nutritional requirements has never been more critical.
This scoping review aimed to identify: the major authoritative reports/guidelines related to healthy
and environmentally sustainable food procurement and foodservice in aged care and healthcare
services released by international and Australian governments/organizations; and the scope of
healthy and environmentally sustainable food procurement and foodservice research and training
initiatives in aged care and healthcare services implemented in Australia over the past decade. A
systematic search yielded n = 17 authoritative reports/guidelines and n = 20 publications describ-
ing Australian research and training initiatives. Implementation of healthy and sustainable food
procurement and foodservices were limited by staff knowledge and self-efficacy, and unsupportive
Citation: Stephens, L.D.; Porter, J.;
management. Further intervention and monitoring of healthy and sustainable food procurement and
Lawrence, M. Healthy and
Environmentally Sustainable Food
foodservice practices is needed. Whilst professionals working in and managing these services require
Procurement and Foodservice in upskilling to apply evidence-based approaches, no system-wide training programs are currently
Australian Aged Care and Healthcare available. There is an urgent need to resolve the existing gap between recommendations to adopt
Services: A Scoping Review of environmentally sustainable practices and staff training across these sectors.
Current Research and Training.
Sustainability 2021, 13, 11207. Keywords: nutrition; environmental sustainability; food procurement; foodservice; aged care; healthcare
https://doi.org/10.3390/su132011207 services; dietetics training
Academic Editors: Adam
Drewnowski and Timothy Griffin
1. Introduction
Received: 25 August 2021
Accepted: 8 October 2021
Balancing dual challenges of meeting nutritional requirements whilst also considering
Published: 11 October 2021
sustainable food systems in the provision of meals in healthcare and aged care has never
been more critical. Historically, the priority in these settings has been to meet nutritional
Publisher’s Note: MDPI stays neutral
needs due to the complex therapeutic dietary needs and the high prevalence of undernutri-
with regard to jurisdictional claims in
tion/malnutrition of which people in these sectors are particularly vulnerable. However,
published maps and institutional affil- the release of multiple global reports over the past decade including from the United
iations. Nations (UN) [1] and EAT-Lancet commission [2] have brought attention to the importance
of all settings and countries delivering sustainable food systems. Healthcare and aged care
food systems are not exempt from these commitments.
A recent systematic review by Carino et al. [3] identified peer reviewed research
across the food supply chain, including production/procurement, distribution, preparation,
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
consumption, and waste management in hospital foodservices. Multiple interventions have
This article is an open access article
been tested across some stages of the supply chain gaps; however, there were notable gaps,
distributed under the terms and particularly in distribution, preparation, and waste management. Most strategies sought to
conditions of the Creative Commons increase consumption/decrease food waste through foodservice models; however, multi-
Attribution (CC BY) license (https:// system interventions were limited. Australia lags behind other countries in progressing
creativecommons.org/licenses/by/ environmentally sustainable foodservice initiatives in healthcare. For example, of the
4.0/).
Sustainability 2021, 13, 11207. https://doi.org/10.3390/su132011207 https://www.mdpi.com/journal/sustainability
Sustainability 2021, 13, 11207 2 of 34
n = 80 papers captured by Carino et al.’s 2020 review [3], only n = 6 were studies conducted
in Australia [4–9] and, of these, n = 3 were conducted by one hospital site [6–8].
No similar review exists in the aged care setting, but similar challenges are known to
exist. The recent Royal Commission into Aged Care Quality and Safety [10] in Australia
drew attention to the challenges of delivering high quality nutrition care within this sector.
Inconsistency in staff knowledge and skills to support nutrition care delivery, poor meal
quality (including variety, texture, and temperature), and insufficient menu budgets were
issues highlighted in some, but not all, residential aged care facilities. Recent Australian
multi-center research showed that only 9.8% of residents completed their main meal
(lunch or dinner) across a 24-h period [11], suggesting that food waste and sustainability
considerations exist across both hospital and aged care sectors.
The coordination of the food system that ensures the safe and reliable supply of food
into healthcare services and aged care systems is complex. Food systems encompass all
components of the food supply chain, extending from the production of food through to its
consumption and disposal. Healthcare services and aged care facilities need to take into
account how their food procurement and foodservice policies and practices are affected
by the rapidly changing nature of modern food systems as well as how they themselves
impact those food systems.
High-quality training is needed across the food and nutrition workforce to preserve
the natural environment and ensure a sustainable food system for future generations [12].
There is an opportunity for nutrition professionals to provide leadership in advocating for
sustainable food systems [12], but workforce training across the broader sector from food
production to waste management may deliver greater intersectoral focus and collaboration
to meet the sustainability agenda.
This scoping review sought to understand the alignment between high-level sustain-
ability reports and guidance that influence food procurement and foodservice practice in
Australian healthcare and aged care sectors, and the opportunities for research and training
for these workforces. Specifically, the review aimed to address the following research
questions:
(a) What are the major authoritative reports/guidelines related to healthy and environ-
mentally sustainable food procurement and foodservice in aged care and healthcare
services released by international and Australian national, state, and local govern-
ments/organizations?
(b) What healthy and environmentally sustainable food procurement and foodservice
research and training initiatives in aged care and healthcare services have been
implemented in Australia over the past decade?
2. Materials and Methods
Drawing on the methodological framework for conducting a scoping review set out
by Arksey and O’Malley [13], a step-wise method was adopted to explore literature around
healthy and environmentally sustainable food procurement and foodservice initiatives in
aged care and healthcare services published in the past decade (2011–2021). A scoping
review approach is appropriate for gaining insights into the breadth and nature of largely
heterogenous literature [13,14]. This method is also feasible when time constraints prohibit
a comprehensive systematic review approach [13,15]. Findings are reported according to
the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for
Scoping Reviews (PRISMA-ScR) [16]. Utilizing such a defined approach aids the reliability
of scoping review findings [16].
2.1. Search Strategy
Scoping review searches were designed and conducted to identify the following
publication types for the two research questions respectively:
(a) authoritative organization reports/guidelines published internationally and in Aus-
tralia; andSustainability 2021, 13, 11207 3 of 34
(b) peer-reviewed journal articles and grey literature (e.g., newsletters, commentary
pieces, healthcare service webpages, etc.) relating to research and/or training initia-
tives and practices in Australia.
Searches were limited to English language literature published between 1st of January
2011 and 31st of May 2021. This time period was selected as it aligns with the release of
the multiple guideline documents released by organizations including the UN and World
Health Organization (WHO). We sought to understand the state of research and training
monitoring, auditing, and initiatives in Australia aligning with these international/national
sustainability reports. Supplementary Material S1 (see Supplementary Materials) outlines
specific details of the literature search strategies for each research question.
2.2. Study Selection Criteria
Inclusion eligibility was kept deliberately broad in order to capture as much literature
around the topic as possible [13]. Material was eligible for inclusion in the review if it
was published online or in a peer-reviewed journal in English. All publication types
(grey literature, for instance, presentation slides, webpages, reports, guidelines; books
and book chapters/sections; and peer-reviewed journal articles, e.g., research studies and
commentary pieces) were included, except for conference abstracts and dissertations. Any
study design type (quantitative and qualitative) was also permitted.
The following search terms were delineated for the purpose of this review. Food
procurement relates to purchasing and foodservice relates to preparation, consumption,
and waste disposal management of foods consumed by patients/clients residing in aged
care or attending healthcare services. ‘Aged care’ encompassed residential aged care
facilities, nursing homes, respite care, or home care. Healthcare services included any
healthcare service where foodservice was provided, e.g., hospitals providing acute and/or
subacute care, mental health inpatient services, and day procedures.
2.3. Data Extraction
Each search was screened manually to remove duplicate publications. Google and
Google Scholar automatically remove similar websites, resulting in few duplicates identi-
fied manually. Once duplicates were removed, full texts of identified relevant literature
were obtained and read to determine eligibility for inclusion in the review. Title/abstract
screening was not possible as the titles and descriptive text about each publication provided
in Google/Google Scholar were not detailed enough to permit such screening. In addition,
the reference lists of included literature were searched; however, no additional publications
were identified.
Data extraction was performed by one author. Key study characteristics were ex-
tracted from identified studies, including publication details, publication type, study
design, funding body type and a summary of findings. Given the scoping nature of the
present investigation, the protocol was not registered on an online review database (e.g.,
PROSPERO), nor was the methodological quality of evidence assessed.
3. Results
Supplementary Material S2 (see Supplementary Materials) shows the flow of liter-
ature through the identification, eligibility, and inclusion screening steps to identify the
major authoritative reports and/or guidelines relating to healthy and environmentally
sustainable food procurement and foodservice in aged care and healthcare services. After
removing n = 3 duplicates, screening was undertaken of n = 171 full text publications,
yielding n = 17 relevant publications. The scope of intended implementation of recom-
mendations/guidelines described in these publications were as follows: n = 4 interna-
tional [17–20], n = 5 national (Australia) [21–25], n = 4 State or Territory [26–29], n = 1 local
government (local council) [30], and n = 3 private sector [31–33]. Figure 1 shows a graphic
summary of key recommendations/guidelines from the relevant authoritative publicationsSustainability 2021, 13, 11207 4 of 34
identified, with greater detail presented in Table A1 (Appendix A). Details including the
publication’s purpose, region of focus, and setting targets were also summarized.
Multiple sectors (international, national, state, local, and private) have consistently
identified a need to unite healthfulness and environmental sustainability in food policy
and initiatives. For example, the Food and Agriculture Organization of the UN (FAO)
and WHO have led the development of recommendations and guidance at the interna-
tional level [17–20]. The guiding principles of the ‘Sustainable Healthy Diets’ goals define
sustainable diets as dietary patterns that promote a person’s health and wellbeing in all
dimensions, have low environmental burden and effect, are safe, readily accessible, afford-
able, and equitable, and culturally acceptable [19]. In 2021, the WHO [20] created an action
framework to support the development and implementation of food procurement and
related service policies for a healthy diet. The framework details methods to develop and
implement a healthy public food procurement and service policy, and provides guidance in
assessing compliance with and evaluating the effectiveness of such policy [20]. The frame-
work also links with the UN’s Sustainable Development Goals described above [1,20], and
incorporates sustainable action via availability of food produced locally and sustainably,
and ensuring sustainable purchasing of local or seasonal food [20].
Five publications recommending the adoption of healthy and environmentally sus-
tainable food procurement and foodservice at the national (Australia) level were identi-
fied [21–25]. The Australian Commonwealth Department of Agriculture, Water and the
Environment released a Sustainable Procurement Guide in 2020 [22]. Governing agen-
cies are encouraged to adopt environmentally sustainable practices, including local food
procurement and foodservice waste reduction [22].
The Climate and Health Alliance submission to the 2019 Climate Health Western
Australia (WA) Inquiry encouraged the uptake of a range of sustainable practices in
healthcare services [26]. For example, sourcing low-emissions foods for hospitals and
healthcare services; supporting and encouraging uptake of a more plant-based diet; and
promoting consumption of a sustainable and healthy diet. Further, healthy eating and
environmentally sustainable practices can be supported by hospitals and healthcare services
through food procurement and demonstrated leadership and prioritizing the purchase of
locally produced foods (incentivizing local farmers to adopt low-emissions/carbon-neutral
practices by harnessing healthcare sector buying power) [26]. A subsequent report stated
that the Climate Health WA Inquiry found a number of healthcare service providers had
begun to build sustainability practices into their procurement processes, but identified the
need to provide more education and training to staff around why sustainable procurement
is important and how it can be achieved [29].
The Dietitians Association of Australia encourages dietitians in all roles across health-
care services to adopt environmentally sustainable practices in the Food Systems and
Environmental Sustainability Role Statement [25]. The Statement highlights dietetics health
professionals as having a crucial role to play in promoting healthy and environmentally
sustainable practices, regardless of role or level of experience. For example, foodservice
dietitians/managers could incorporate food/water systems principles into procedures;
determine training needs to build environmental sustainability capacity amongst staff to
ensure sustainable practices are adopted; focus on local food procurement policy develop-
ment, implementation, monitoring; and implement food waste minimization strategies.
Tertiary educators of dietetics students could integrate environmental sustainability and
food systems education into the curriculum across all areas of dietetic practice [25]. Similar
guidance and recommendations promoting the adoption of healthy and environmentally
sustainable food procurement and foodservice practices were identified at state [26–29],
local [30], and private sector [31–33] levels (see Table A1 for full summary).Sustainability 2021, 13, 11207 5 of 34
Figure 1. Graphic synthesis of key guidelines and/or recommendations drawn from major authoritative reports/guidelines about healthy and environmentally sustainable food
procurement and foodservice in healthcare and aged care services.Sustainability 2021, 13, 11207 6 of 34
Supplementary Material S3 (see Supplementary Materials) shows the flow of pub-
lications arising from two searches relating to the second research question. In the first
part, a Google search yielded n = 3190 hits, with the first n = 100 hits screened once n = 6
duplicates were removed. No additional pertinent literature was identified (beyond over-
lapping literature identified in the following Google Scholar search), and consequently
the remaining screening of the Google search yield was discontinued. In the second part,
Google Scholar was searched for relevant literature. A total of n = 445 records remained
after 11 duplicates were removed. Screening of titles/abstracts identified n = 83 potentially
relevant publications. Of these, n = 20 relevant publications arose from full text screening.
Among the 20 studies identified, n = 10 examined food procurement/food service research
and n = 11 examined education/training (one study explored foodservice and training).
Publication details, funding body type, and summarized findings from the relevant
studies exploring healthy and environmentally sustainable practices in food procurement
and foodservice research in healthcare and aged care services are presented in Table 1.
Research studies investigating healthy and environmentally sustainable initiatives focused
on food procurement [34–36], foodservice [3,37–40], and both food procurement and
foodservice [41,42].
Several best practice healthy and environmentally sustainable food procurement prac-
tices identified in healthcare and aged care settings included procuring food locally [34,41,42]
and establishing food growing gardens on site [35,36]. Foodservice initiatives to incor-
porate healthy and environmentally sustainable practices were also identified. These
included redesigning menus to increase appropriate vegetarian and vegan options [37],
meal ordering closer to mealtime consumption [3,41], and increased mealtime assistance
for patients with dexterity issues [3]. Facilities also reduced food packaging and/or in-
creased recycling [38,41], monitoring of food waste [40], and sharing audit results with
staff [41]. Food waste management policies were developed [38,39,41,42], and food waste
used to produce compost [3]. Finally, hospitals formed sustainability groups in hospitals
supported by leadership [37], with engagement with local communities to share successes
and learnings around environmental sustainability [36].
Figure 2 presents a graphic synthesis of findings from studies that explored healthy
and environmentally sustainable practices in food procurement and foodservice research,
education, and training for nutrition and dietetics students and other healthcare profession-
als (with detailed data extracted from those studies presented in Table A2 (Appendix B).
Four studies analyzed existing Australian curriculum content related to healthy and envi-
ronmentally sustainable practices in nutrition and dietetics undergraduate/postgraduate
courses [12,43–45] and found there is a need for related modules, and opportunities ex-
ist to strengthen the depth to which sustainable food system modules are taught and
assessed [12,43,45], despite a recognized need in a reworking of nutrition and dietetics
professionals’ required competencies [44]. For example, in an analysis of the breadth and
depth to which sustainable food systems were taught to Australian nutrition and dietetics
students, Carino, McCartan and Barbour (2020) identified 130 relevant degrees, among
which only 8% included modules about the sustainable food systems [12].
In addition to needing greater incorporation of environmental sustainability into
curricula for undergraduate and postgraduate nutrition/dietetics courses, increases in
nutrition and dietetics students’ knowledge, skills, and self-efficacy to implement such
practices are also required [46,47]. In 2020, Burkhart et al. [46] found that students had vary-
ing levels of familiarity with sustainability-related concepts around economic resilience,
environmental integrity, social development, and cross-cutting issues. Most (82%) stu-
dents thought sustainability was very important in general, with almost two-thirds (63%)
recognizing sustainability was specifically important for professional practice [46].Sustainability 2021, 13, 11207 7 of 34
Figure 2. Graphic synthesis of findings from literature describing research, education and training related to healthy and
environmentally sustainable food procurement and foodservice practices and initiatives in aged care and healthcare services
in Australia between 2011–2021.
Early and mid-career nutrition/dietetics professionals who are working in and man-
aging food procurement and foodservice roles require upskilling and bolstered confidence
to implement state-of-science practices to ensure Australia’s health services and aged care
facilities adopt recommended actions. Four studies explored knowledge, skills, and compe-
tencies among nutrition and dietetics professionals already practicing in healthcare [48–51]
and tertiary educators’ knowledge and views about teaching healthy and environmen-
tally sustainable practices [49,50]. A recent study by Brand et al. (2021) [48] showed that
while most (90%) educators of healthcare professionals had strong content knowledge
about sustainable healthcare, fewer felt confident to explain such content (36.9%), or to
inspire interest in students about sustainable healthcare practices (44.2%). Further, two
thirds of educators felt they did not know how best to teach sustainable healthcare edu-
cation [48]. Worsley et al. (2014) reported that practicing dietitians were keen to increase
their knowledge about the impact of food production systems on nutrient composition,
sustainability, food selection, and related issues [51]. Professional development could be
accessed by discussion groups and workshops, professional development courses, and on-
line webinars [51]. There were limited mentions of other healthcare professionals engaged
in this content.
Examination of funding provided to support the research detailed in the n = 20 studies
summarized in Table A1 (Appendix A) and Table A2 (Appendix B) showed that six studies
did not provide any information about funding. Of the remaining n = 14 studies, three
specifically stated that they had not received any funding. The Australian Commonwealth
supported one study, the State Government of Victoria funded two studies, one study
was supported by a non-Government organization, and the remaining six studies were
supported by the private sector (University, n = 5; Meat and Livestock Australia, n = 1).Sustainability 2021, 13, 11207 8 of 34
Table 1. Publication details, funding body type, and findings from literature addressing healthy and environmentally sustainable food procurement and foodservice research in healthcare
and aged care services implemented in Australia between 2011 and 2021.
Study Type;
Author(s) (Year) Funding Body Type Summary of Findings
Region; Setting
• Study aimed to assess the influence of the Food Alliance (an organization that aims to promote
integrative food policy development addressing structural determinants of healthy and
sustainable eating; and to create a healthy, environmentally sustainable, fair, and economically
thriving food system)
• Food Alliance activities and work:
- To provide a resilient fruit and vegetable supply for Victoria
Analysis of Food Alliance
- Implement healthy and environmentally sustainable public sector food procurement
Caraher et al. (2013) [34] work; Victoria; healthcare Not funded
- Develop healthy and environmentally sustainable food policy
services
• Examples of Food Alliance influence on other organizations:
- VicHealth food systems component: VicHealth recognizes the need for sustainable food supply
and procurement
- Healthy food procurement for government and funded services: Victorian Department of
Health has implemented a project to develop food procurement guidelines to increase healthy
food choices across government-funded sectors
• A systematic review was undertaken to explore the environmental sustainability of hospital
foodservices. A brief summary of findings specifically related to address our own review’s
purpose is provided (i.e., Australian research exploring hospital food waste):
• Of six studies conducted in Australia [4–9], three were conducted on a single hospital site [6–8]
Systematic literature review; • Compared to traditional methods of foodservice, food (plate) waste was reduced when
Carino et al. (2020) [3] international (including University (private sector) patients:
Australia); hospitals - ordered from an on-demand bedside electronic meal ordering system (BMOS) [4,7]
- ordered from an on-demand room service menu [6,8]
- were served pureed foods in a shaped form (molded) [5]
• Vermicast (worm castings) was the most economical for use in institutional-scale worm farms
for composting hospital food waste [9]Sustainability 2021, 13, 11207 9 of 34
Table 1. Cont.
Study Type;
Author(s) (Year) Funding Body Type Summary of Findings
Region; Setting
• Qualitative study among operational and management level staff with responsibilities for
policy, purchasing, production, onsite plating, delivery, and waste disposal in three hospitals in
Victoria
• The study aimed to explore staff’s perspectives about sustainable practices in hospital food
provision; existing barriers and facilitators; and recommendations for future implementation of
sustainable foodservice practices
• Findings:
- Sustainable practices currently employed included use of recyclable packaging, effective
equipment and technology, and adoption of efficient processes
- Unsustainable practices included food source restrictions (e.g., not able to purchase locally
Qualitative individual produced foods), use of packaging that cannot be separated or recycled, inflexible foodservice
Carino et al. (2021) [41] University (private sector)
interviews; Victoria; hospitals models and menu, and excessive waste production, and inadequate waste processes
- Facilitators of improved sustainability included individuals’ power to affect change, provision
of education on recycling, knowledge generation, audits of current processes, grants for
innovative research, rebates, and processes to improve quality
- Barriers restricting the adoption of sustainable practices included conflicting priorities, poor
communication, lack of knowledge and training opportunities, restrictions relating to infection
control, and insufficient policy, funding, and time between meal ordering and delivery
- Proposed modifications to the existing processes were practice changes across the entire food
supply chain, and generation and sharing of knowledge, leadership, and policy support
- Foodservice staff perspectives show a shared motivation and desire to adopt and implement
sustainable foodservices, with support needed from leaders and policy
• Described eight lessons learned from introducing sustainability practices at the organizational
level: implementation (Lesson 1), multi-level leadership (2), inclusive initiatives that direct
Charlesworth, Stewart and Perspective paper; New South
Not reported participants to relevant resources (3), measure sustainability indicators to monitor progress (4),
Sainsbury (2018) [37] Wales (NSW); hospitals
environmentally sustainable practices are diverse (5), facilitation of effective engagement (6),
network-building (7), and encouraging political awareness (8)Sustainability 2021, 13, 11207 10 of 34
Table 1. Cont.
Study Type;
Author(s) (Year) Funding Body Type Summary of Findings
Region; Setting
• Examples of barriers to effective engagement (Lesson 6):
- Occasionally, resistance to environmentally sustainable initiatives was encountered from
professional groups who felt that such initiatives contrasted with their professional objectives
- e.g., a hospital sustainability committee suggested adopting a ‘meat-free Monday’ to improve
health, reduce carbon emissions, and would have symbolic importance. However, nutritionists
Charlesworth, Stewart and Perspective paper; New South opposed the idea, viewing daily meat on hospital menus as essential to correct malnutrition in
Not reported
Sainsbury (2018) [37] Wales (NSW); hospitals some patients (an issue viewed as critical by the nutritionists)
- It is therefore important to emphasize that environmentally sustainable actions are aligned with
a healthcare organization’s other objectives (i.e., provide quality healthcare; improve patient
experience; operate with greater efficiency, consistency, and relevance; and financial sustainability).
- Hence environmental sustainability can be another incorporated dimension of quality
healthcare services
• Using an aged care service case study, the study presents a ‘Double Diamond’ process to
develop context-specific environmental sustainability strategies by employing streamlined Life
Cycle Assessment and design thinking
• Discussion of ideas to improve environmental sustainability in the aged care facility’s
foodservice identified the following steps:
- facility menu planned in consultation with patients and families
- patient meal requests added to menu
- menu approved by nutrition expert
- food purchased for a 4-week menu cycle
- Tasmania purchases food through government schemes
Clune and Lockrey Qualitative case study;
Not reported - local prison grows and prepares fresh vegetables for Tasmania’s sites
(2014) [42] Tasmania; aged care service
- fruit and vegetables delivered three times/week
- food is delivered
- food prepared and cooked in central onsite kitchen
- pre-prepared meats used often, however with a preference for fresh
- food is consumed
• Three strategies to engage with and reduce environmental impacts associated with food:
- Food diet strategy - low carbon menu planning (resulting in up to 25% reduction in food
impacts)
- Food waste strategy (up to 5% reduction in food impacts)
- Aged care as a site of productionSustainability 2021, 13, 11207 11 of 34
Table 1. Cont.
Study Type;
Author(s) (Year) Funding Body Type Summary of Findings
Region; Setting
• Detailed a cross-sectional study to examine the amount of waste generated in hospital
foodservice, waste disposal practices and associated cost
• Strategies are needed to:
- Avoid food waste in the first place
# Reducing time between ordering and eating
# High quality food
# Mealtime assistance
# Forecasting
# Plated meals
- Avoid sending food waste to landfill
Cross sectional study
# Reuse and donation limited by infection control concerns (however this is changing)
Collins (2019) [38] (presentation slides); Australia; Not reported
# Worm farm
hospitals
# In-vessel composting
# Drying via dehydration
# Anaerobic digestion
- Reduce single use plastic packaging:
# Use real crockery, cutlery, and reusable plastic containers
# Re-useable plastic crates or material bags
# Cook fresh or adopt plated food service systems
- Separate and recycle plastic, paper, tins
# Time
# Accessible labelled bins
• Review aimed to identify methodological features of hospital foodservice food waste audits
Systematic literature review; via measurement of aggregate food and food-related waste; and to develop a hospital foodservice
Cook et al. (2021) [40] international (including University (private sector) food waste audit tool.
Australia); hospitals • Among the studies yielded, only one Australian study was identified. That same study was
captured in the present review; see Collins 2019 [38] above for a brief summary of findings.Sustainability 2021, 13, 11207 12 of 34
Table 1. Cont.
Study Type;
Author(s) (Year) Funding Body Type Summary of Findings
Region; Setting
• Study aimed to identify current healthy and environmentally sustainable practices in
healthcare services explicitly identifying climate change as a priority
• Case 5 hospital (health promotion coordinator interviewed):
- Hospital established an onsite community garden to support diverse health promotion and
environmentally sustainable programs (prompted by regional food security issues including
Patrick and Capetola Qualitative case studies; affordability and availability of fresh food)
State Government
(2011) [35] Victoria; hospital - Partnerships with multiple stakeholders (e.g., local school, council, local businesses) provided a
foundation for the establishment of the garden
- The garden provided (among other community health promotion programs and activities) a
sensory garden for patients and aged-care residents
- Internal program evaluations demonstrated improved social connectedness and mental and
physical health, and greater biodiversity and food production
• Study aimed to identify key barriers and facilitators to community healthcare services
incorporating sustainability into their practices
• Case study 4 (primary care partnership on climate change and rural adjustment):
- Several projects relating to food, water, transport, heatwaves, and resilience were planned and
implemented
- Practice issues related to difficulties in developing partnerships with other services, and, while
projects had received funding, those projects did not appropriately engage the target population
- In direct contrast, an advantage of the healthcare service was its ability to create partnerships
across community groups
• Case study 5 (healthcare service providing services spanning from acute care through to health
Qualitative case studies and
promotion):
Patrick et al. (2011) [36] key stakeholder interviews; State Government
- An onsite community garden promoted local food production and access to fresh food supply
Victoria; healthcare services
(among other non-food-related outcomes)
- A key barrier to the garden initiative was community engagement, with public concern for
appearance of the garden when it was first established, and questioning the existence of
environmental issues the garden aimed to address
- Support for the garden initiative included providing the public with a way to address their
expressions of interest to grow fresh and healthy food; and members of the public have proved
keen advocates of the initiative
• Findings from all five case studies show that despite several barriers (e.g., funding allocation,
lack of policy direction), healthcare services can implement healthy and environmentally
sustainable practicesSustainability 2021, 13, 11207 13 of 34
Table 1. Cont.
Study Type;
Author(s) (Year) Funding Body Type Summary of Findings
Region; Setting
• Hospital patients’ perceptions, beliefs, and expectations relating to hospital food waste
• Patients identified the following contributors to hospital food waste:
- patient appetite and interest in food
- food quality and quantity
- foodservice model
• Three key strategies to reduce hospital food waste:
Porter and Collins Qualitative individual Non-Government
- Foodservice modifications needed to decrease waste
(2021) [39] interviews; Victoria; hospitals Organization
- Employ multiple methods for food waste management
- Non-food waste also needed to be reduced and managed
• Barriers to food waste management:
- Contamination
• Hospital patients felt the overall amount, management and impacts of hospital food waste was
unseen and unknown by them
BMOS: Bedside electronic meal ordering system; NSW: New South Wales.Sustainability 2021, 13, 11207 14 of 34
4. Discussion
The present scoping review identified several publications detailing the need to in-
corporate healthy and environmentally sustainable food procurement and foodservice
practices in healthcare and aged care services, across international, national (Australia),
state/territory, local and private sectors. The adoption of healthy and environmentally
sustainable dietary patterns are important for addressing UN Sustainable Development
goals [1]. There is recognition at the international and national level that nutrition and di-
etetics professionals bridge the gap between healthy diets and environmentally sustainable
food procurement and foodservice.
Studies identified in this review also showed that while healthy and environmentally
sustainable practices have begun to be successfully integrated into healthcare and aged
care services, particularly around procurement and foodservice, there remains a disconnect
between international and local policy documents and the implementation of strategies
into practice in these key settings. Multiple barriers were described, for example, lim-
ited staff knowledge and confidence to advocate and implement healthy and sustainable
practices [50,51]. Similarly, tertiary educators of nutrition and dietetics students lacked
confidence to incorporate environmental sustainability into the curriculum [48]. Therefore
unsurprisingly, several studies demonstrated that nutrition and dietetics education and
training tertiary and professional development courses lacked integrated sustainability
training [12]. This void needs to be addressed by curricula reforms to bring emerging and
current nutrition and dietetics professionals’ practice in line with international recommen-
dations, particularly in the Australian context.
There were notable gaps in the evidence presented in Table A2 (Appendix B), suggest-
ing that implementation of sustainable foodservice initiatives is occurring more quickly in
the healthcare rather than the aged care sector. Given the attention delivered by the Royal
Commission into Aged Care Quality and Safety [10], and the current implementation of
new funding commitments [52], it is evident that further research into monitoring and
auditing healthy and environmentally sustainable practices is needed in this sector.
As a result of these findings, there are multiple implications for academics and practi-
tioners alike. For academics, it is challenging for the development of recommendations to
change practice both in the health and aged care sectors if the workforce is not appropriately
skilled. There is critical need for curriculum change; the need for our future workforce to
be trained in food and nutrition sustainability initiatives has never been more crucial. For
current practitioners, engagement in the sustainability narrative is essential for impactful
practice in both sectors. Professional organizations and specialized training opportunities
may be able to support ongoing professional education of the pre-existing workforce to
ensure that clinicians are able to deliver contemporary practice.
Although not specified as a research question, we acknowledge that First Nations
Australians have used sustainable initiatives to manage the land for many thousands of
years. The involvement of Indigenous Australians to the literature regarding sustainable
foodservice systems in hospitals and aged care services was noticeably absent.
Two issues that were not identified within this scoping review but which may inform
development of a future strategy and policy for implementing healthy and sustainable
food systems in aged and health care are organic farming and local food production
and procurement.
Organic farming generally considers farming practices with an emphasis on long
term sustainability. Organic growers in Australia have been described as “a heterogenous
cluster of organizations and individuals whose beliefs are at times congruent, at other times
divergent” [53]. One of the reasons for the relatively underdeveloped organic farming sector
is the reduced regulatory framework in Australia as compared with other countries [54].
Local food purchasing practices have been established in multiple institutions interna-
tionally. “Local food” typically relates to production, processing, and raw material [55].
In Australia, there is a growing awareness of the need to support local food systems
with some local and state governments now advocating for reform to mandate local foodSustainability 2021, 13, 11207 15 of 34
production and procurement [56–58]. Both approaches warrant further consideration for
implementation of sustainable practices across these sectors.
This review also identified that limited funding support has been provided to Aus-
tralian researchers and educators to implement and evaluate environmentally sustainable
initiatives in hospital and aged care foodservices. With considerable investment for Tier 1
national grants programs (including Australian Research Council, National Health and
Medical Research Council, and Medical Research Future Fund), this subject has not pre-
viously been viewed as a priority for funded research. This has follow-on effects with
specialist training available for future leaders in the field.
Several strengths and limitations to this review are acknowledged. Database search
strategies were untaken using broad search terms to ensure that eligible studies were
included. The inclusion of English language studies only is recognized as a limitation, as
is the reliance on publicly accessible databases (Google and Google Scholar) rather than
scientific databases. This was unavoidable to the rapid nature of this review.
5. Conclusions
There is a growing need to implement healthy and sustainable food systems in the
healthcare and aged care services sectors in Australia. This scoping review identified a gap
that exists between international and Australian policy recommendations on healthy and
environmentally sustainable foodservices and their translation into practice in these sectors.
We also identified limited funding for research and training on this topic, and access to
education and training remains under-resourced. There is an urgent need to resolve these
deficits if Australia is to close the gap to other countries in implementing food system
sustainability in these sectors.
Supplementary Materials: The following are available online at https://www.mdpi.com/article/
10.3390/su132011207/s1, Supplementary Material S1: Scoping review literature search strategies;
Supplementary Material S2: Flow diagram of publication screening to identify major authorita-
tive reports/guidelines related to healthy and environmentally sustainable food procurement and
foodservice in aged care and healthcare services; and Supplementary Material S3: Flow diagram of
publication screening to identify literature describing healthy and environmentally sustainable food
procurement and foodservice research and training initiatives in aged care and healthcare services
implemented in Australia between 2011–2021.
Author Contributions: Conceptualization, L.D.S., J.P. and M.L.; methodology, L.D.S., J.P. and M.L.;
formal analysis, L.D.S.; data curation, L.D.S.; writing—original draft preparation, L.D.S., J.P. and
M.L.; writing—review and editing, L.D.S., J.P. and M.L. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received funding from Institute for Physical Activity and Nutrition (IPAN),
School of Exercise and Nutrition Sciences, Deakin University.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.Sustainability 2021, 13, 11207 16 of 34
Appendix A
Table A1. Summary of major authoritative reports/guidelines about healthy and environmentally sustainable food procurement and foodservice in healthcare and aged care services.
Summary of Healthy and Environmentally Sustainable food Procurement and Food Services
Author(s) (Date) Publication Details Region; Setting
Guidelines/Recommendations
International
• Greening the Economy with Agriculture:
- ‘Availability—Food availability and natural resource use, in a green economy context’
- ‘Access—Decent rural livelihoods and rights in a green economy environment’
- ‘Stability—Stability of food security in a green economy environment’
Four working papers presented - ‘Utilization—Improving food systems for sustainable diets in a green economy’
Food and Agriculture
at the UN Conference on • Healthy and environmentally sustainable food procurement and foodservice practices in United
Organization of the UN International; Hospitals
Sustainable Development States (US) hospitals were presented as an example of local food utilization [59]:
(FAO) (2012) [17]
(Rio+20) process - Local government and private corporate hospitals in the US joined the ‘Health Care Without Harm
Healthy Food Pledge’
- The Pledge aims to increase fruit, vegetables, and minimally processed foods. Hospitals are also
obliged to adopt sustainable food procurement (e.g., local food purchases), and to promote and
provide education about healthy foods to patients
From p33 of Annex 2: ‘Outcome of the meeting of civil society organizations’:
• To guarantee sustainability and resilience in biodiversity and dietary diversity, nutrition must be
supported by local food systems that are based on the following:
- food sovereignty
Report by the Joint FAO/WHO - small-scale food producers
Secretariat on the Second - agroecological principles
FAO and WHO (2014) International; Healthcare
International Conference on - sustainable use of natural resources, local seeds, and livestock breeds
[18] and aged care services
Nutrition (19th to 21st - traditional knowledge and practice, and
November 2014) - local markets
• To significantly improve nutrition and greatly contribute to the prevention of malnutrition, civil
society organizations called for the following:
- Recognition that resilient, small-scale, food producer-led local food systems are best placed to
respond to climate change threats to adequate nutritionSustainability 2021, 13, 11207 17 of 34
Table A1. Cont.
Summary of Healthy and Environmentally Sustainable food Procurement and Food Services
Author(s) (Date) Publication Details Region; Setting
Guidelines/Recommendations
International
- a commitment to intensive actions to strengthen local food systems via promotion of local and
regional markets, and safeguarding healthy ecosystem
Report by the Joint FAO/WHO
- ensure the establishment of appropriate local food policy governance bodies that involve
Secretariat on the Second
FAO and WHO (2014) International; Healthcare multi-actor partnerships. Further, such bodies should include consumers and small-scale local food
International Conference on
[18] and aged care services producers
Nutrition (19th to 21st
- adopt reforms to current local food procurement practices such that they include privilege for the
November 2014)
provision of fresh local produce by small-scale local producers in public food services (e.g., school
canteens, homes for the elderly, hospitals, other public institutions, and social groceries)
• ‘Sustainable Healthy Diets’ are defined as dietary patterns that:
- promote an individual’s health and wellbeing in all dimensions
- have low environmental burden and effect
- are safe, readily accessible, affordable, and equitable
International; applies to
- are culturally acceptable
Outlines guiding principles of any setting in which
• ‘Sustainable Healthy Diets’ aim to:
FAO and WHO (2019) the FAO and WHO healthy nutrition and
- Support all individuals in all life stages to achieve optimal growth and development, and support
[19] ‘Sustainable Healthy Diets’ sustainability intersect
function and physical, mental, and social wellbeing for present and future generations
goals (including healthcare and
- contribute to preventing malnutrition in all forms, i.e., undernutrition, micronutrient deficiency,
aged care services)
overweight and obesity
- reduce diet-related non-communicable disease risk
- support the protection and maintenance of biodiversity and planetary health
• Sustainable healthy diets must combine all sustainability dimensions
• Healthy public food procurement and service policies set nutrition criteria to be applied in public
settings. These criteria aim to increase availability of foods that promote a healthy diet and/or limit or
International; applies to prohibit availability of foods contributing to an unhealthy diet (e.g., foods high in sodium, sugars, and
Action framework for
any setting in which fats – particularly saturated and trans fats).
developing and implementing
healthy nutrition and • Healthy food procurement ties in with the UN’s Sustainable Development Goals #2 (end all forms
WHO (2021) [20] public food procurement and
sustainability intersect of malnutrition), #3 (promote healthy lives and well-being), and #12 (promote sustainable
service policies for a healthy
(including healthcare and procurement practices in accordance with national policies and priorities) [1]
diet
aged care services) • Among other benefits, heathy public food procurement service policies can bolster availability of
nutritious, affordable, and culturally acceptable food produced locally and sustainably. As
governments are large purchasers of food, such purchasing power can achieve:Sustainability 2021, 13, 11207 18 of 34
Table A1. Cont.
Summary of Healthy and Environmentally Sustainable food Procurement and Food Services
Author(s) (Date) Publication Details Region; Setting
Guidelines/Recommendations
International
- Increased availability of healthy food by policies incentivizing food producers and industry to
supply healthier options
- Support sustainable diets by promoting healthy food that is sustainably produced, giving
producers and industry further incentive to use environmentally sustainable agricultural production
methods to ensure biodiversity
- Promote locally sourced healthy food through increased purchasing of fresh, unprocessed food
from local producers and farmers (in turn stimulating local economy, reducing climate impact, and
increasing local income and employment opportunities)
- Promotion of culturally acceptable, local healthy food. Using indigenous crops and species and
local and traditional recipes can help promote food cultures, stimulate biodiversity (by producing a
variety of crops and plant species), and support elements of cultural preservation and environmental
sustainability
• The key guiding principles for healthy public food procurement and service policies are:
International; applies to
Action framework for - Informed by evidence
any setting in which
developing and implementing - Apply a human rights-based approach
healthy nutrition and
WHO (2021) [20] public food procurement and - Safeguard public interests
sustainability intersect
service policies for a healthy - Incorporate health in all policies across public sectors
(including healthcare and
diet - Establishment of safe, healthy and sustainable diets
aged care services)
• Governments need to establish nutrition and other criteria within policies for public food
procurement and service, e.g., to ensure safer food handling and preparation, and sustainable
purchasing of local or seasonal food. Good practices for developing such nutrition criteria include:
- Describing nutrition criteria in clear terms that reduce the likelihood of misinterpretation
- Ensure criteria are comprehensive enough to achieve the desired outcome
- Extend and build on established criteria
- Determine whether nutrition labelling is available, adequate, or in need of strengthening
- Tailor policies to specific populations and contexts (e.g., in hospitals, aged care services, etc.)
- Other criteria may include promotion of sustainable practices, or sourcing food locally (e.g., setting
limits on the number of servings of animal-based food products per day/week; stipulate a set number
of plant-based meals offered per day/week; determine a proportion of procured food to be free from
antibiotics/hormones; establish criteria to reduce food loss and wastage; and set criteria to
minimize/eliminate use of plastics and their derivatives in food packagingSustainability 2021, 13, 11207 19 of 34
Table A1. Cont.
Summary of Healthy and Environmentally Sustainable food Procurement and Food Services
Author(s) (Date) Publication Details Region; Setting
Guidelines/Recommendations
National
• Discussion paper aimed to identify critical control points for transforming the food system
towards one that is more healthy, environmentally sustainable, and equitable.
• Three critical control points identified:
- reduce the profitability of discretionary and unsustainable foods
Australia; applies to any - increase profitability of core foods
2017 Theo Murphy High Flyers
Backholer et al. (2017) setting in which healthy - improve availability of core foods
Think Tank discussion paper:
[21] nutrition and • Proposes changes to food procurement strategies as a way to address health and sustainability
“The food environment”
sustainability intersect issues:
- Public food procurement initiatives to improve healthy diets are being implemented by many
countries. Widespread implementation of such policies would increase the availability of healthy
foods to those serviced by those food systems, with the additional benefit of potentially increasing
demand for healthy foods as well as driving food reformulation by manufacturers.
• Details sustainable procurement guidance across a range of good and services.
• Adoption of sustainable procurements aims for the reduction in adverse social, environmental,
and economic impacts of purchased goods and services over the course of their use, e.g., waste
disposal, operation costs, and maintenance over the life of goods and services. Australian
Government officials are encouraged to consider these impacts when making procurement decisions,
while efficiently, effectively, economically, and ethically balancing public money spending.
• Provides case study of environmentally sustainable measures adopted in a hospital (Germans
Department of
Sustainable Trias i Pujol University Hospital, Spain, p51):
Agriculture, Water and
Procurement Guide for use by - Sustainability criteria and a 3R strategy (reduce, reuse, recycle) are applied to food procurement.
the Environment, Australia; hospitals
Commonwealth (Australia) Implemented initiatives include:
Commonwealth of
bodies’ procurements. - Reduction in plastic water bottle use by introducing reusable water bottles in the canteen
Australia (2020) [22]
- Encouraging staff and visitors to recycle by providing recycling areas for different container types
- Replacing all single-use containers in catering with reusable materials
- Replacing and reducing single use containers with biodegradable materials in dining rooms and
vending machines
- Monitoring food sustainability measures with performance indicators including total food waste
from patient meals, reduced total food waste, and efficiency in reducing environmental impact of
packaging used in coffee shops (see strategic procurement in European healthcare report [60]).You can also read
