Sustainable Food Consumption in Nursing Homes: Less Food Waste with the Right Plate Color?

Abstract

The problem of unsustainable food consumption among vulnerable residents of nursing homes who suffer from dementia is often multifaceted. From an individual perspective, people with dementia who do not finish their meals are likely to encounter serious health issues associated with malnutrition. Moreover, at the institutional level, nursing homes generate tons of nonrecoverable food waste each year, impairing not only their economic position but also the natural and social environment at large. The purpose of this study is to explore the possibility of reducing food waste in Norwegian nursing homes by appraising how large this reduction could be as one replaces traditional dining white porcelain with plates with diverse color combinations. A quasi-experimental method was adopted. The results of the pilot study were extrapolated to the annual amount of food wasted at the national level. The findings indicate that, on average, 26% of food was thrown away when served on white plates compared to only 9% when served on one of the colored plate options tested. Nationally, approximately 992.6 tons of food per year could potentially be saved with only a single change, ultimately ameliorating the unsustainable food consumption problem among residents of nursing homes.

Full text

Sustainability 2020, 12, 6525; doi:10.3390/su12166525 www.mdpi.com/journal/sustainability
Article
Sustainable Food Consumption in Nursing Homes:
Less Food Waste with the Right Plate Color?
Kai Victor Hansen * and Lukasz Andrzej Derdowski
Norwegian School of Hotel Management Ullandhaug, University of Stavanger, NO-4036 Stavanger, Norway;
lukasz.a.derdowski@uis.no
* Correspondence: kai.v.hansen@uis.no
Received: 24 June 2020; Accepted: 10 August 2020; Published: 12 August 2020
Abstract: The problem of unsustainable food consumption among vulnerable residents of nursing
homes who suffer from dementia is often multifaceted. From an individual perspective, people with
dementia who do not finish their meals are likely to encounter serious health issues associated with
malnutrition. Moreover, at the institutional level, nursing homes generate tons of nonrecoverable
food waste each year, impairing not only their economic position but also the natural and social
environment at large. The purpose of this study is to explore the possibility of reducing food waste
in Norwegian nursing homes by appraising how large this reduction could be as one replaces
traditional dining white porcelain with plates with diverse color combinations. A quasi-
experimental method was adopted. The results of the pilot study were extrapolated to the annual
amount of food wasted at the national level. The findings indicate that, on average, 26% of food was
thrown away when served on white plates compared to only 9% when served on one of the colored
plate options tested. Nationally, approximately 992.6 tons of food per year could potentially be
saved with only a single change, ultimately ameliorating the unsustainable food consumption
problem among residents of nursing homes.
Keywords: food waste; sustainability; nursing home; plate colors; pilot study
1. Introduction
Generally, food waste is perceived as an ecological, economic, and social problem. Existing
estimations of global food production and consumption indicate that every year roughly
1.3 billion tons of food are lost or wasted [1,2]. The gravity of the situation has been recognized by the
United Nations, which issued a list of Sustainable Development Goals (SDGs) that included a 50%
reduction per capita in global food waste at the retail and consumer levels by 2030 (Goal 12:
“Responsible Consumption and Production” [3]). Similarly, Borzan [4] articulates the concern that
“for every kilogram of food produced, 4.5 kg of CO
2
are released into the atmosphere; whereas in
Europe the approximately 89 Mt of wasted food generate 170 Mt CO
2
eq./yr” (pp. 4–5). When one
considers the complexity of the entire food supply chain (i.e., production/procurement, distribution,
preparation, consumption, and waste management/disposal [5]), it becomes apparent that, next to
food waste and emissions, vast resources (e.g., energy, water, and land) are also being dissipated
every year. Thus, from a global perspective, the waste of edible food appears to have far-reaching
implications for environmental, social, and economic conditions of individuals and society at large.
Moreover, existing research supports the assertion that the foodservice sector accounts for a
considerable percentage of the total food wasted within the confines of the food supply chain. For
instance, it has been reported that the European Union (EU) foodservice sector produces
approximately 12,263,210 tons of food waste per year, accounting for 14% of the total food waste
generated [6]. Furthermore, several authors [7] argue that the level of meal waste tends to vary

Sustainability 2020, 12, 6525 2 of 9
according to the type of foodservice setting being investigated, such as schools and universities,
workplace restaurants and canteens, or hospitals and nursing homes. As an illustration, Engström
and Carlsson-Kanyama [8] report 9–11% meal waste in some school foodservices. Norton and Martin
[9] find 17% waste in a university dining hall environment and waste in elderly nursing care centers
between 20% and 27% of the food produced [10,11].
Having recognized the previously mentioned arguments, this study aims to contribute to the
line of research examining the unsustainable food waste problem in institutional settings.
Specifically, we scrutinize through a (quasi-) experimental manipulation of how plates with different
color combinations influence the amount of food wasted among people with dementia living in
nursing homes in Norway. For the sake of specificity, as the definition of “food waste” is not
universally shared, [12] in this article, it refers to waste from food that is not eaten from the plates on
which they are served. Throughout this paper, the terms “food waste” and “plate waste” are used
interchangeably.
2. Food Waste Problem in Nursing Homes
It has long been advocated that consumer behavior is critical in today’s society in the fight for a
more sustainable future. This includes meeting organizers such as the World Food Summit in
Copenhagen, where various organizations and groups meet every year to discuss, among other
things, food waste as part of sustainability in the world. [13] Residents of nursing homes that offer
care and services for those no longer able to live independently represent a group of people who do
not have the same opportunities to decisively affect their consuming patterns. In fact, people with
dementia living in nursing homes receive all their care, including all meals, from staff members
working there. According to WHO Dementia [14], dementia is chronic and progressive; cognitive
function deteriorates beyond what might be expected from normal aging. Most people affected by
dementia are 65–90+ years. It affects memory, thinking, orientation, comprehension, calculation,
learning capacity, language, and judgment and has major consequences when sufferers perform
activities in everyday life [15]. Regular and balanced food and fluid intake represent a case in point.
Indeed, malnutrition is found between 10% and 60% of patients in Norway’s hospitals and nursing
homes [16,17]. Undernutrition increases this rate up to 70% [18]. For persons with dementia, this risk
is increased due to physical and psychological changes, which lead to lower food intake, combined
with age-related malnutrition risks [19,20]. One can argue that these conditions present a challenge
for most countries that have an aging population.
Worldwide, an estimated 21 million people suffered from dementia in 2009, and experts predict
that this number will increase to 81.1 million by 2040 if no treatment methods for dementia are found
[21]. In the Norwegian context, people with long-developed dementia often live in sheltered wards.
According to the latest estimates, approximately 70,000 individuals have dementia, and this number
is expected to increase to 140,000 by 2040 [15,18,22]. That number is significant in the whole world,
and the estimates and projections today indicate considerably large numbers [21].
Norway had 942 nursing homes in 2018 [23], providing about 40,000 places with capacity close
to 100%. Every day of the year, dinner is served to all these nursing home residents. An estimated
80% of long-term residents in nursing homes have dementia [24], which is equivalent to
approximately 32,000 people. The number of dinners served throughout the year is then
approximately 11.6 million and appropriate dinnerware, such as plates, cups, and mugs, needs to be
in place and preferably in a shape that encourages people to eat.
A 1997 study indicated a reduction in food waste in long-term care homes when using
dinnerware instead of tray service [25]. This may be related to residents feeling as if they were in their
own home when they ate dinner [17]. According to Hackes et al. [25], family-style service produced
the least food waste among three different serving methods.
Food waste accounts for a large part of waste in industrialized parts of the world and contributes
to the fact that important nutrients are not used for human consumption, but instead go to waste and
create environmental problems of great magnitude [26]. Food waste in hospitals, nursing homes, and
other health facilities contributes to the total food waste, and is often referred to as plate waste [27].

Sustainability 2020, 12, 6525 3 of 9
The reduction in food waste in nursing homes affects vulnerable groups of people. Today, there may
be several strategies for reducing food waste, as suggested in the article by Williams and Walton, [27]
such as clinical, food and menu, service, and environmental issues.
A previous study that focused on dinnerware color versus the traditional white dishes on which
the vast majority of Norwegian nursing homes served dinners in 2015/16 concluded that people with
dementia less often ate all the food on the white plates compared to food served on different colored
plates [28]. Although the authors of this study focused on several aspects related to porcelain,
dementia, and colors, they did not offer an assessment of food waste per se [28]. In a similar vein, a
study by Rossiter and associates presents an alternative of a completely blue crockery used among
elderly patients in an acute setting and concludes that colored porcelain was associated with
increased food intake, [29] yet again no food waste amount was estimated.
Sustainability in the health sector and food service has been discussed and recommended in a
Danish study [30] conducted over an 8 year period. The results showed little progress in public
hospitals when it came to sustainable food systems for elderly people.
Therefore, given these arguments, we endeavor to explore the possibility of reducing food waste
in Norwegian nursing homes by appraising how large this reduction could be by simply replacing
traditional white porcelain dinnerware.
3. Method
To achieve the overall estimates of meal intake from estimates of individual food ingestion, it is
necessary to perform some sort of calculation [31]. Therefore, this scholarly endeavor employed the
following quantitative methodological approach.
3.1. Research Design and Data Collection Procedure
Whereas a given research design is often seen as a blueprint for a study, this project utilized an
exploratory approach where no a priori (theory-driven) hypotheses were tested [32]. Instead, our
primary objective was to explore the subject in question so as to provide ideas and insights that could
potentially serve as an initial step for future investigations. Furthermore, in order to go beyond the
frequently employed, yet not uniformly appreciated, survey method, [33] we put to use the quasi-
experimental method instead [34]. Thus, for the purpose of this investigation, four plate types with
different color compositions were designed (see Figure 1), where the white plate (A) option was
treated as a baseline for comparisons. Of relevance, plates where all food was eaten were counted
and marked as fully consumed food. The different plate combinations are described outside each
image, and the interventions were carried out in that particular order. The surveys were conducted
on random days over a three-week period.
Figure 1. The different plate types used in this research: photo by author. Explanation of the different
plates: Plate (A): white porcelain (a baseline for comparisons). Plate (B): yellow well, red lip, and red
ring around the edge. Plate (C): white well, green lip, and blue rim on the edge. Plate (D): white well,
yellow rim, and red ring around the edge.

Sustainability 2020, 12, 6525 4 of 9
Concerning the data collection procedure, this project was conducted at a nursing home in
Rogaland County in Norway among people with dementia. It was carried out on two wards, with
altogether 12 residents (five females) between 65 and 85 years; all residents had been diagnosed with
dementia. The departments received the dinner meal in food containers directly from the communal
kitchen. The staff put the food on the plates, which they then served. Plates subsequently collected
by the staff were analyzed to determine whether they were with or without food residue. Some of
the residents needed special diets, which were laid out ready-made from the communal kitchen and
delivered together with the other meals. The staff served the ready-made plates to each resident. All
photography was performed in a separate post kitchen to avoid disturbing residents before, during,
and after the meal. Altogether, 88 pictures were taken, which resulted in 44 pairs of photographs
(pre- and postconsumption) viable for further analysis.
3.2. Photo Analysis
In general terms, food waste can be measured directly by weighing the amount of food waste or
estimated indirectly by, for example, visual estimations [35]. Given the diverse data collection
techniques, this pilot project used data extracted through an indirect approach. Specifically, each dish
was photographed before the serving occurred and later on when the plates were returned to the
post kitchen. To keep the track of incoming/outcoming dishes, all plates were marked with a unique
code. Finally, when all paired pictures were in place, an estimate of the percentage of actual food
consumed was derived for each meal. The following formula was adopted to capture the amount of
food wasted in a single meal: FW
i
(in %) = 100% − FC
i
(in %), where FW
i
is food waste from ith single
meal and FC
i
is food consumed in ith single meal.
3.3. Ethical Concerns
As this scholarly endeavor focuses on individuals who belong to so-called vulnerable
populations [36], the following processes were established to ensure ethical conduct during the study.
Information and consent forms were provided to the nursing home before the intervention. Separate
forms were provided for staff and residents and adjusted for their role in the study. Nursing home
managers distributed the consent forms, provided information to residents and their families, and
brought in the consent forms. When residents were not able to give consent, a relative’s vicarious
consent was used. The project was submitted for research approval to the Norwegian Centre for
Research Data (NSD) and was approved (No: 44818/3/LT).
4. Results
4.1. Experimental Results
The results presented in this quasi-experimental pilot study are based on the calculation of
uneaten food during dinner by an individual with dementia who lives in a nursing home. The next
section offers extrapolated calculations of how much food waste would occur during a year among
people with dementia in Norway if one used different types of plates designed with a focus on color.
As for the results derived from the pilot project, the food waste when using traditional white
porcelain (option A, see Figure 1) was on average equal to 26% (N
A
= 11, M = 0.26, SD = 0.28, range
from 0 to 0.80). This estimate is in line with approximations found in existing literature, as several
authors have asserted that 20% to 27% of food produced in nursing homes is being wasted [10,11].
Plate B manipulation (yellow well, red lip, and red ring around the edge) resulted in an average food
waste of 10% (N
B
= 10, M = 0.10, SD = 0.17, range from 0 to 0.40). Furthermore, the second
manipulation (Plate C, white well, green lip, and blue rim on the edge) led to an average food waste
of 22% (N
C
= 12, M = 0.22, SD = 0.22, range from 0 to 0.60). The last condition (Plate D, white well,
yellow rim, and red ring around the edge) recorded the least waste at 9% (N
D
= 11, M = 0.09, SD =
0.14, range from 0 to 0.40).

Sustainability 2020, 12, 6525 5 of 9
4.2. Extrapolated Results
Table 1 presents the extrapolated results of our study, taking into account general statistics
unique to the context of Norwegian nursing homes (as described in Section 2) and the findings
obtained from the pilot project.
Table 1. Estimates for plate waste and potential saving of food waste depending on different plate
color.
1
2
3
4
5
6
7
8
Plate
Type
Nursing
Home
Beds in
Norway
Average
Number of
People with
Dementia
Average
Weight of
a Dinner
(in kg)
Weight of
Dinners
Served in
365 Days
(in tons)
Average
Percentage
of Plate
Waste
Dinner
Plate
Waste in
Norway
(per year,
in tons)
Saving of
Food Waste
(Plate A as a
Baseline, per
year, in tons)
40,000
80%
0.5 kg
365 days
Pilot test
A
40,000
32,000
16,000
5840
26%
1518.4
-
B
40,000
32,000
16,000
5840
10%
584
934.4
C
40,000
32,000
16,000
5840
22%
1284.8
233.6
D
40,000
32,000
16,000
5840
9%
525.6
992.6
Our data reveal that, if dinners served to elderly people with dementia continue to be delivered
on traditional white porcelain, it will produce approximately 1518.4 tons of food waste (per year)
from this single meal (column 7 in Table 1). However, introducing color-based variants into the
design of pottery can possibly lead to saving a nonnegligible amount of meal waste. That is, our crude
estimates imply that around 934.4 tons of food per year (column 8 in Table 1) could potentially be
spared by introducing Plate B’s design in nursing homes in Norway. Plate C’s design could save up
233.6 tons of meal waste, whereas Plate D’s design could save the biggest amount of food, equaling
992.6 tons per year.
Available literature on food waste has long recognized the distinction between edible food and
nonedible food as well as between recoverable and nonrecoverable food [37]. The recoverable food
category includes surplus food from restaurants, grocery stores, and cafeterias, whereas
nonrecoverable food consists of animal bones, shells, and skin as well as uneaten food
prepared/served by institutions. The latter argument is of particular relevance here. Food waste in
nursing homes represents a major challenge in that food served to residents is more difficult to reuse
for further human consumption. The number of kilos per day that go to waste from residents who
do not eat all of the food served is not desirable, but when the amount of food waste throughout the
year is considered, it becomes a challenge. The estimates presented imply that the savings are the
greatest between Plate A and Plate D, which could save 992.6 tons per year for all of Norway.
Regardless, the results clearly indicate that, of all plates, food served on white plates comes out the
worst compared to the other three plates with color combinations.
4.3. Sources of Bias
The estimated results are based on several different calculated figures. Different norm numbers
were extracted and approximated including dinner portion weight in kilogram per person, number
of nursing home places in Norway, number of individuals with dementia in nursing homes in
Norway, and percentage of dinners not fully eaten from different color combinations in the pilot
project. Thus, it is necessary to point out several sources of errors that might confound our
estimations. Regardless of their magnitude, in our view, the presented evidence should still be a cause
for concern when considering sustainable food consumption among residents with dementia in
Norwegian nursing homes.
One potential source of error in the study is the small number of individuals who participated
in the pilot project, meaning our conclusions may not necessarily be transferred directly to the whole
country. The small sample size also did not allow us to statistically test and verify differences in food

Sustainability 2020, 12, 6525 6 of 9
waste production across the four investigated quasi-experimental conditions (e.g., using an ANOVA
test).
A second possible source of error is that various dishes were served on the different intervention
days. The residents may have liked the food better on one day than the other day. In addition, the
same staff did not serve meals every single intervention day. This may have led to a greater variation
in how the food was served and added up. There might have been large differences between
consistently adapted food from the kitchen and how the food was plated. A last source of error was
that the kitchen manual that provided pictures to show what the dinner plates should look like was
oftentimes not used by the staff.
5. Discussion
According to Borzan [4], “[t]o reduce food waste, improve food safety as well as enhance the
overall sustainability of food production, research and development have a highly important role to
play in all sectors of the food supply and consumption chain” (p. 29). Of relevance, past research
points to the fact that food waste in developing countries occurs primarily in the postharvest stages,
whereas food waste in developed countries (such as Norway) occurs primarily in the consumer and
postconsumer stages [38]. Thus, this project focuses on (un)sustainable food consumption patterns
observed among residents of Norwegian nursing homes who suffer from dementia.
The discussion is based on the original findings published that showed how much food was
eaten in terms of the colors of dinnerware on which the food was served. This was the relevant issue
when the project was conducted. The result was that all types of dinnerware with colors showed a
greater effect in the number of dinners eaten among people with dementia. The data indicated that
the white plate used to serve dinner at the nursing home resulted in the fewest residents eating all
the food on the plate.
In this article, any food not eaten by the residents was considered food waste. This means that
any measures that can increase food intake and reduce food waste will be important in the fight for
the better utilization of food for the sake of ensuring a sustainable future (as emphasized by the
United Nation’s Sustainable Development Goals).
However, at a more fundamental level, food that is eaten provides the necessary energy, protein,
minerals, vitamins, and other nutrients humans need for a good life. There are many areas that can
stimulate increased food intake, but the focus of this article was how changing color combinations on
a plate would affect the appetite of people with dementia.
The group that participated in this research project (often described as a vulnerable population)
included people with a diagnosis of dementia. They need a regular supply of food to prevent
malnutrition, from which many elderly people suffer. It is important that food is eaten to prevent
malnutrition and that people with dementia receive natural nutrients and the building blocks for
their body. An equally important part is that food waste needs to be reduced. A reduction in food
waste among people with dementia in nursing homes faces several challenges, but the benefits of the
elderly eating more food affect the individual occupant, the nursing home, the community, and
finally, the natural environment.
As previously noted, food served on a plate to people in nursing homes cannot be reused and
must be considered as food waste. The food is then treated as if it were contagious and cannot be
destined for any further human consumption. In general terms, it is important that the risk of any
possible infection is reduced, and that the food follows current laws and legislations such as, e.g.,
hazard analysis and critical control points (HACCP) and other national regulations [39,40]. Thus,
food leftovers produced in nursing homes cannot be reused in any way that would resemble, for
instance, several hotel chains and restaurant strategies (i.e., where they offer mobile apps such as
”Too Good To Go” where one can purchase food at a discounted price that would otherwise be
thrown away). From a sustainability perspective, it is, therefore, important that as many residents of
nursing homes as possible eat the food being served. The basic premise is that everyone should be
fed on white porcelain. However, our findings suggest that white dinnerware can be associated with
the largest amount of food waste, while Plate D can save more than 992.6 tons of food per year. The

Sustainability 2020, 12, 6525 7 of 9
amount of food served on average on one plate was 0.5 kg per person per day [41]. Different
interventions with white plates versus colorful plates showed different outcomes in terms of food
waste from the various servings. The figures are based on estimates documented through various
sources and research [41–43]. The lowest estimate is 525.6 tons of food waste if all nursing homes
switched to the colored plate that showed the best result (Plate D) rather than continuing to use white
plates. As a final thought, it is important to note that the provided estimations relate to only one meal
(i.e., dinner). If other meals are considered when determining the amount of food waste avoided,
even greater prosustainable changes could occur that would perhaps make a considerable difference
to the environment and the people directly affected.
Taken together, improving the efficiency of food production and consumption, as well as
changing the general diet in Western countries, appear to be vital for securing the sustainable future
of food supply. Along this line, several authors contend that food waste occurring in particular at the
end of the food supply chain (i.e., consumption) is especially harmful to the environment and
economy due to the resources invested and emissions produced while growing, transporting, and
retailing foodstuffs [44,45]. Having considered the gravity of the situation, this scholarly endeavor
brings in a possible solution for ameliorating the unsustainable food consumption problem
specifically among residents of nursing homes.
6. Conclusions
The findings of this article indicate that with only a single change (such as redesigning the colors
of dinnerware), a lot of food can be eaten instead of it turning into waste in institutions such as
nursing homes. Although this was just a pilot project, the estimated number of tons of food saved
from waste is tremendous (i.e., up to 992.6 tons of food per year). It seems that sustainable
consumption at institutions such as nursing homes has not received adequate attention thus far, and
we believe that this stream of research holds the potential to benefit individuals (e.g., residents’
health), institutions (e.g., their general food expenses), and/or the natural environment at large (e.g.,
by producing less nonreusable food waste).
Therefore, further research should look at conditions that encourage nursing home residents to
eat more of the food being served, especially people with dementia, who make up a large proportion
of these residents. Several measures can be adopted and (e.g., experimentally) manipulated to
comprehend how, for instance, the size of the plate, atmosphere in the dining room, brightness in the
food room, or diverse plate colors encourage or discourage overall food consumption and waste
production among the elderly with dementia living in nursing homes.
Author Contributions: Conceptualization, K.V.H.; Formal analysis, L.A.D.; Investigation, K.V.H.; Methodology,
L.A.D; Project administration, K.V.H.; Software, L.A.D; Validation, K.V.H.; Writing – original draft, K.V.H.;
Writing – review & editing, L.A.D. All authors have read and agreed to the published version of the manuscript.
Funding: This study was funded through the public policy system VRI (policy instrument for regional
innovation and development). The authors would like to thank everyone at the nursing home where the study
was conducted.
Acknowledgments: This project would not have been possible without the close cooperation of the nursing
home in Rogaland County.
Conflicts of Interest: The authors declare no conflicts of interest.
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