Healthy and Environmentally Sustainable Food Procurement and Foodservice in Australian Aged Care and Healthcare Services: A Scoping Review of Current Research and Training

: Balancing the adoption of environmentally sustainable food systems in Australian healthcare 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 describing Australian research and training initiatives. Implementation of healthy and sustainable food procurement and foodservices were limited by staff knowledge and self-efﬁcacy, and unsupportive management. Further intervention and monitoring of healthy and sustainable food procurement and foodservice practices is needed. Whilst professionals working in and managing these services require upskilling to apply evidence-based approaches, no system-wide training programs are currently available. There is an urgent need to resolve the existing gap between recommendations to adopt environmentally sustainable practices and staff training across these sectors.


Introduction
Balancing dual challenges of meeting nutritional requirements whilst also considering 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 needs due to the complex therapeutic dietary needs and the high prevalence of undernutrition/malnutrition of which people in these sectors are particularly vulnerable. However, the release of multiple global reports over the past decade including from the United 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, consumption, and waste management in hospital foodservices. Multiple interventions have been tested across some stages of the supply chain gaps; however, there were notable gaps, particularly in distribution, preparation, and waste management. Most strategies sought to increase consumption/decrease food waste through foodservice models; however, multisystem interventions were limited. Australia lags behind other countries in progressing environmentally sustainable foodservice initiatives in healthcare. For example, of the n = 80 papers captured by Carino et al.'s 2020 review [3], only n = 6 were studies conducted in Australia [4][5][6][7][8][9] and, of these, n = 3 were conducted by one hospital site [6][7][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 sustainability 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 environmentally sustainable food procurement and foodservice in aged care and healthcare services released by international and Australian national, state, and local governments/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?

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)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019)(2020)(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].

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 Australia; and (b) peer-reviewed journal articles and grey literature (e.g., newsletters, commentary pieces, healthcare service webpages, etc.) relating to research and/or training initiatives 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.

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.

Data Extraction
Each search was screened manually to remove duplicate publications. Google and Google Scholar automatically remove similar websites, resulting in few duplicates identified 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 extracted 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.

Results
Supplementary Material S2 (see Supplementary Materials) shows the flow of literature 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 recommendations/guidelines described in these publications were as follows: n = 4 international [17][18][19][20], n = 5 national (Australia) [21][22][23][24][25], n = 4 State or Territory [26][27][28][29], n = 1 local government (local council) [30], and n = 3 private sector [31][32][33]. Figure 1 shows a graphic summary of key recommendations/guidelines from the relevant authoritative publications 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 international level [17][18][19][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, affordable, 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 framework 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 sustainable food procurement and foodservice at the national (Australia) level were identified [21][22][23][24][25]. The Australian Commonwealth Department of Agriculture, Water and the Environment released a Sustainable Procurement Guide in 2020 [22]. Governing agencies 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 healthcare 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 development, 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][27][28][29], local [30], and private sector [31][32][33] levels (see Table A1 for full summary). Supplementary Material S3 (see Supplementary Materials) shows the flow of publications 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 overlapping 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.
Several best practice healthy and environmentally sustainable food procurement practices 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 incorporate 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 increased 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 professionals (with detailed data extracted from those studies presented in Table A2 (Appendix B). Four studies analyzed existing Australian curriculum content related to healthy and environmentally sustainable practices in nutrition and dietetics undergraduate/postgraduate courses [12,[43][44][45] and found there is a need for related modules, and opportunities exist 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 varying levels of familiarity with sustainability-related concepts around economic resilience, environmental integrity, social development, and cross-cutting issues. Most (82%) students thought sustainability was very important in general, with almost two-thirds (63%) recognizing sustainability was specifically important for professional practice [46]. Early and mid-career nutrition/dietetics professionals who are working in and managing 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 competencies among nutrition and dietetics professionals already practicing in healthcare [48][49][50][51] and tertiary educators' knowledge and views about teaching healthy and environmentally 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 education [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 online 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). • 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][5][6][7][8][9], three were conducted on a single hospital site [6][7][8] • Compared to traditional methods of foodservice, food (plate) waste was reduced when patients: -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]  • 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 produced foods), use of packaging that cannot be separated or recycled, inflexible foodservice 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 Charlesworth, Stewart and Sainsbury (2018) [37] Perspective paper; New South Wales (NSW); hospitals Not reported • Described eight lessons learned from introducing sustainability practices at the organizational level: implementation (Lesson 1), multi-level leadership (2), inclusive initiatives that direct participants to relevant resources (3), measure sustainability indicators to monitor progress (4), environmentally sustainable practices are diverse (5), facilitation of effective engagement (6), network-building (7), and encouraging political awareness (8) • 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 opposed the idea, viewing daily meat on hospital menus as essential to correct malnutrition in 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 Clune and Lockrey (2014) [42] Qualitative case study; Tasmania; aged care service Not reported • 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 -local prison grows and prepares fresh vegetables for Tasmania's sites -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 production • Review aimed to identify methodological features of hospital foodservice food waste audits via measurement of aggregate food and food-related waste; and to develop a hospital foodservice food waste audit tool.
• 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. • 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 affordability and availability of fresh food) -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 Qualitative case studies and key stakeholder interviews; Victoria; healthcare services State Government • 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 promotion): -An onsite community garden promoted local food production and access to fresh food supply (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 practices

Discussion
The present scoping review identified several publications detailing the need to incorporate 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 dietetics 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, limited 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 recommendations, particularly in the Australian context.
There were notable gaps in the evidence presented in Table A2 (Appendix B), suggesting 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 practitioners 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 internationally. "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 food production and procurement [56][57][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 Australian 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 previously 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.

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.

Conflicts of Interest:
The authors declare no conflict of interest.  • 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 -small-scale food producers -agroecological principles -sustainable use of natural resources, local seeds, and livestock breeds -traditional knowledge and practice, and -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 nutrition International; Healthcare and aged care services -a commitment to intensive actions to strengthen local food systems via promotion of local and regional markets, and safeguarding healthy ecosystem -ensure the establishment of appropriate local food policy governance bodies that involve multi-actor partnerships. Further, such bodies should include consumers and small-scale local food producers -adopt reforms to current local food procurement practices such that they include privilege for the 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)

Appendix A
FAO and WHO (2019) [19] Outlines guiding principles of the FAO and WHO 'Sustainable Healthy Diets' goals International; applies to any setting in which healthy nutrition and sustainability intersect (including healthcare and aged care services) • '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 -are culturally acceptable • 'Sustainable Healthy Diets' aim to: -Support all individuals in all life stages to achieve optimal growth and development, and support function and physical, mental, and social wellbeing for present and future generations -contribute to preventing malnutrition in all forms, i.e., undernutrition, micronutrient deficiency, 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 WHO (2021) [20] Action framework for developing and implementing public food procurement and service policies for a healthy diet International; applies to any setting in which healthy nutrition and sustainability intersect (including healthcare and aged care services) • 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 prohibit availability of foods contributing to an unhealthy diet (e.g., foods high in sodium, sugars, and fats -particularly saturated and trans fats).
• Healthy food procurement ties in with the UN's Sustainable Development Goals #2 (end all forms of malnutrition), #3 (promote healthy lives and well-being), and #12 (promote sustainable procurement practices in accordance with national policies and priorities) [1] • 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: Table A1. Cont.

Author(s) (Date) Publication Details Region; Setting Summary of Healthy and Environmentally Sustainable food Procurement and Food Services Guidelines/Recommendations
International WHO (2021) [20] Action framework for developing and implementing public food procurement and service policies for a healthy diet International; applies to any setting in which healthy nutrition and sustainability intersect (including healthcare and aged care services) -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: -Informed by evidence -Apply a human rights-based approach -Safeguard public interests -Incorporate health in all policies across public sectors -Establishment of safe, healthy and sustainable diets • 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 packaging  [21] 2017 Theo Murphy High Flyers Think Tank discussion paper: "The food environment" Australia; applies to any setting in which healthy nutrition and sustainability intersect • 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 -increase profitability of core foods -improve availability of core foods • Proposes changes to food procurement strategies as a way to address health and sustainability 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.

Department of
• 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 Trias i Pujol University Hospital, Spain, p51): -Sustainability criteria and a 3R strategy (reduce, reuse, recycle) are applied to food procurement. Implemented initiatives include: -Reduction in plastic water bottle use by introducing reusable water bottles in the canteen -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]). • Defines an Australian practicing dietitian's (APD) role in fulfilling environmental sustainability requirements in food systems and promotes APD's knowledge and expertise in this arena.
-ADP required skills relating to healthy and environmentally sustainable practices (among others): -Identification of relevant environmental sustainability practices, and translation into effective interventions and/or practice -Identify highly credible evidence, suitable policies or practice intervention, and key stakeholders; frame advocacy potential tasks while establishing a mutually beneficial situation for advocating change -Key stakeholder engagement across a range of sectors • ADP required knowledge relating to healthy and environmentally sustainable practices (among others): -Understanding healthy and environmentally sustainable practices within industrialized and local food systems -Policy intervention opportunities and challenges to achieve food system reform at each food system phase (i.e., agricultural production, food processing, distribution, retail, consumption, and food waste) -Understanding and application of behavior change theory to identify key motivators and drivers to encourage healthy and environmentally sustainable dietary behavior and food practices • Healthy and environmentally sustainable food-related practices for ADPs to promote: -Avoiding over-consumption beyond caloric requirements -Limiting consumption of highly processed, nutrient poor and over-packaged foods -Consuming no more than the recommended amounts of animal-derived foods (and those that are produced sustainably and ethically) -Increasing plant-based food intake -Eating seasonally • Provides key recommendations to adopt environmentally sustainable practices in healthcare services • Public health can be promoted, and healthcare system pressure reduced by sourcing low-emissions foods for hospitals and healthcare services • Leading health authorities support and encourage the shift to a more plant-based diet to address public health and environmental issues • Promoting consumption of a Mediterranean diet and adherence to the Australian Dietary Guidelines supports consumption of a sustainable and healthy diet • Hospitals and healthcare services can support healthy eating and environmentally sustainable practices through food procurement and demonstrated leadership • Preferentially purchasing locally produced foods can reduce transport-related carbon emissions while benefitting local producers. Healthcare sector buying power can incentivize local farmers to adopt low-emissions/carbon-neutral practices • One of four arms of the Engagement and Action Trial for the Tasmanian Food and Nutrition Strategy is related to Tasmanian local food procurement.
• Institutions (including hospitals and aged care facilities) will be supported to transition to local procurement • Suggested actions include: -audits to establish proportion of locally procured food benchmarks -securing institution partnerships -reinforcement of the Tasmanian 'Buy Local' policy -economic analysis of benefits to jobs and local spending • In-kind support that could contribute to the plan's success includes identifying opportunities to build food and nutrition related actions into other government priorities (e.g., trialing institutional food procurement in a public setting such as hospitals or correctional facilities) Queensland Health, State of Queensland Government (2017) [28] Toolkit for dietetic services demand management Queensland; hospitals and aged care services • Modification to foodservice requires a whole of organization approach, requiring a dietitian to work as part of a broader team to ensure a healthy and environmentally sustainable foodservice • The foodservice dietitian role may therefore include the development, review and evaluation of organizational procedures and processes, and advocating nutrition-related issues • Environmental sustainability should be maximized in systems and supplier agreements wherever possible, e.g., by reducing food waste, packaging, water and energy use, while increasing procurement of locally sourced foods • Dietitians are encouraged to actively advocate for foodservice systems that are known to improve dietary intakes and consumer outcomes. They should identify and act on issues impacting menu nutrition content through proposing feasible solutions that account for financial, environmental and sustainability constraints. This can be achieved by conducting assessments of procurement strategies, forecasting systems, production and distribution principles and methods, food waste, and, if applicable, equipment fit-out and kitchen layout. • The Inquiry aimed to identify methods to adapt to climate change to protect community health • The WA Sustainable Procurement Policy provides guidance to the healthcare sector on how to integrate sustainability considerations into the procurement process among other types of procurement, food procurement in the healthcare sector is important for reducing the healthcare sector's emissions. The Inquiry found: -Several healthcare service providers have started to build sustainability practices into their procurement processes -there is a recognized need to provide more education and training to staff around the importance of sustainable procurement and how it can be implemented -strong leadership and a broad culture focused on climate impact and sustainability is needed to drive behavior change relating to sustainable procurement

Local government (Australia)
City of Ballarat (2019) [30] City of Ballarat Council meeting agenda Ballarat (regional city of Victoria); hospitals, aged care services • Describes Council initiatives for managing food waste in relevant settings (p531) and improving food quality in hospitals and aged care services (p532) • Food waste service provider: -Council has a role as the principal provider in waste collaboration. The aim therefore is to harness the ongoing productivity of food waste by allocating organic waste from landfills into industrial worm farms (resulting in job creating and reduced greenhouse gas emissions) -Food scraps can be collected in Council's green waste collection from a range sources (including hospitals and aged care services, among others) • Addressing food quality in hospitals and aged care services: -Hospitals and aged care services produce large amounts of food waste. Some reasons include cutting costs in food quality, over-portioning, not catering to tastes of patients/residents/clients, poor institutional food procurement practices and poor storage -Addressing food quality will: result in improved nutritional outcomes for patients/residents/clients, in turn resulting in better health outcomes; reduce institutional food waste and cost; and improved consumer perception of those institutions • Study explored undergraduate nutrition and dietetics students' awareness and perceived importance of healthy and environmentally sustainable practices • Students were more familiar with the term environmental sustainability and related concepts than economic or social sustainability • Students had varying levels of familiarity with 42 sustainability related concepts in the domains of economic resilience, environmental integrity, social development, and cross-cutting issues • Most students thought sustainability was very important in general (82%), and specifically for professional practice (63%) • More than half (65%) of students recognized the need for government led initiatives to address future sustainability • This study aimed to describe how widely modules about sustainable food systems are taught to nutrition and dietetics students in Australia, and examine the depth to which those modules are taught and assessed • 130 relevant degrees were identified, among which only 8% (n = 9) included modules about the sustainable food systems • The most commonly taught topics across the 16 mapped modules, according to their learning outcomes, included sustainable food systems, local vs industrial food systems, food policy, and issues related to production, processing, distribution, retail, and consumption of food. Topics less commonly taught included agricultural practices, food-related ethical issues, healthy and environmentally sustainable diets, food sovereignty, food waste impacts, food system change opportunities and health message impacts on the food supply • As sustainable food systems are emerging as a field for nutrition professionals, there is opportunity for more related higher education modules in Australia, and opportunities exist to strengthen the depth to which sustainable food system modules are taught and assessed.
Carlsson, Mehta, and Pettinger (2019) [43] Book chapter; international; healthy and environmentally sustainable practices across healthcare sectors Not reported • Chapter details incorporating sustainable food systems into dietetics practice • Current dietetics curricula pay attention to the food system and sustainable eating to varying degrees of depth, however primarily the main focus tends to be on biomedical aspects of nutrition and healthy eating. This suggests dietetic graduates are less likely to be equipped to work in the emerging field of sustainable eating.
• Consensus is growing that sustainability needs to be incorporated into higher learning • Barriers to increase dietitians' food system and sustainability literacy include inadequate time in the curriculum, lack of practical training opportunities (e.g., few knowledgeable instructors) • Student training and professional development founded on a clear understanding of terms, concepts and current issues relating to food systems and environmental sustainability is essential to enable practitioners to play strategic roles in future • Editorial presents a general discussion about nutrition professionals requiring better training in environmental sustainability (in relation to food security) • Future needs of nutrition professionals to address food insecurity: -The emerging paradigm of sustainable food and nutrition security poses major challenges to nutrition practice -A proposed multi-sectoral approach requires nutrition professionals to acquire new skills sets and foster a greater appreciation of non-traditional fields -Strong advocacy skills are vital across the food security analytical, capacity building, and intervention management levels, however this is overtly missing from most educational programs currently -Academic research nutrition professionals also need to become better advocates -The topics of agriculture, ecology, biodiversity, climate change science, sustainability, economics, and community development are also absent from many nutrition curricula, hence precluding nutrition professionals from meaningfully entering the sustainability debate Dunphy (2014) [50] Qualitative individual interviews; Australia; healthy and environmentally sustainable practices across healthcare sectors

Australian Commonwealth
• Study aimed to identify key obstacles to healthcare professionals supporting environmental sustainability and potential strategies to overcome such obstacles • Views among healthcare professionals (including nutritionists and dietitians): -More action is taken to protect the environment in participants' personal rather than professional lives, particularly among those with strong professional identities -A key barrier to implementing environmentally sustainable practices in the healthcare sector was the focus on economic rationalism (i.e., that efficiency and productivity are primary measures of economic success) -Concerns about conflict and professional ostracism if environmental sustainability actions are taken -Not feeling qualified to act (e.g., academics teaching healthcare students do not feel comfortable to cover environmental sustainability issues within coursework) -Lacking professional development about environmental sustainability exacerbates feelings of lacking knowledge (e.g., exposure to environmental sustainability information was most often in the context of home, but not the workplace) -Professional development is critical to permit healthcare professionals to advocate and implement environmentally sustainable actions at work -Nutrition science -Food and the food system the chemical composition, properties, and reactions of nutrients/foods and effect on (among others) sustainable food production systems (including agricultural systems, technology, and farming) multi-level impact of food technologies, food sustainability and food supply on food security/insecurity and subsequent influence on health and disease -Nutrition governance, sociocultural and behavioral factors Historical and current factors (including social, economic, environmental, institutional, and political contexts) that influence food supply, food sustainability and individual and population food choices Social determinants of health that influence food supply, food sustainability, food choices, dietary patterns, health, and well-being across population groups -Nutrition research and critical analysis -Communication and professional conduct • Three specialist competency areas were also identified: -Food science Complexities of sustainable food production (agricultural science and technology), reformulation, production, processing, manufacturing, distribution, fortification, and food technology Food supply limits arising from changes in environmental conditions, global events, and political science -Public health nutrition Employ appropriate health, nutrition and behavior change theories, education, and health promotion to improve nutrition outcomes that are equitable and sustainable for across population groups -Animal nutrition Animal farming systems impacts on environment (particularly energy use, emissions, and greenhouse gases) • Details a scoping review protocol to explore environmental sustainability education and training among foodservice dietitians and dietetics students • Rationale for proposed review: -At present, there are no requirements for Australian dietitians to learn about environmental sustainability during their education -As they work in a variety of health settings, dietitians are well placed to mitigate climate change, e.g., via reduction of hospital carbon emissions -Foodservice can have the greatest impact on environmental sustainability, as foodservice dietitians work with kitchen staff to develop hospital menus. Foodservice dietitians can support reduction in carbon emission impacts through reducing food waste; prioritizing purchase of locally produced food; reducing the amount of 'high carbon emissions' foods on the menu (e.g., meat); maximizing refrigeration, heating, and cooking process efficiencies; and reduction of single-use plastics -In Australia, few nutrition and/or dietetics degrees contain sustainable food systems learning modules. In part this may be due to the environmental sustainability criterion being removed from the DAA competency standards (see DAA Competency standards in Table A1 (Appendix A) above [23]). Australian university dietetics curricula are required to comply with DAA competency standards, thus currently there is no mandated requirement by the accredited authority for dietetics students (i.e., dietitians of the future), to develop knowledge and skills relating to environmental sustainability -While Australian universities do recognize the importance of improving environmental sustainability, inclusion of such teachings into health curricula is minimal. Hence there is uncertainty about the readiness of healthcare professionals including dietitians to drive environmentally sustainable practices -Identification of pedagogical frameworks used in educational institutions and professional development providers is needed to understand how foodservice dietitians and dietetic students gain knowledge and training in environmental sustainability practices • Select Australian example integrating healthy and environmentally sustainable principles into training for healthcare professionals (e.g., shows dietitians): -Integrating sustainability into the Masters of Dietetics course at Bond University (Queensland, Australia) -Sustainability activities introduced: Visits to farmers' market, supermarket, and commercial farm. Activities included: a food miles activity; a related pricing activity; answering questions about packaging transparency on the environmental cost of the food; discussion about Food Citizenship concept; workshop and debate exploring "paddock to plate" concepts and principles (organic vs conventional farming practices Cooking exercise: Learn core culinary/food literacy skills Visit to local hospital with a Room-Service-on-Demand food service system. Activities included learning benefits of such a model (i.e., minimize plate and production waste; and the cook-fresh system enables decreased packaging, menu tailoring to be more sustainable, and shopping locally) Lecture and workshop: Future of food and environmental sustainability Workshop: Learnings around environmental sustainability in food service (international context), practicality of applying core food sustainability principles in commercial foodservice, and assessing sustainable recommendations to a rural hospital Food service placements: Explore environmental sustainability issues (e.g., measuring plate and production waste, recycling practices, environmental sustainability needs assessment at placement sites). Communicated findings to key stakeholders and other students -Resulting outcomes of implemented teaching and training activities: Almost all (95%) of students felt confident/very confident to make dietary recommendations regarding environmental sustainability; and all (100%) believed sustainability should be within a dietitian's scope of practice, and agreed sustainability is a global issue that needs to be addressed • Australian dietitians were surveyed to investigate dietitians' perceptions about sustainability and agricultural issues, and determine their need for information about agriculture and primary foods (specifically what information is required, and how would it be employed in practice) • Dietitians indicated they wanted to receive more information about food production systems impact on nutrient composition, sustainability, food selection and related issues • Dietitians preferred to learn about such issues via discussion groups and workshops, professional development courses, and online webinars DAA: Dietitians Association of Australia; UN: United Nations.