Abstract
Background Hospitals have a responsibility to support human health, and given the link between human and environmental health, hospitals should consider their environmental impacts. Hospital foodservices can negatively affect the environment at every stage of the food supply chain (production/procurement, distribution, preparation, consumption, and waste management/disposal). Objective To systematically identify and synthesize the following across the hospital patient food/nutrition supply chain: environmental and associated economic impacts of foodservice; outcomes of strategies that aim to improve the environmental sustainability of foodservice; and perspectives of patients, staff, and stakeholders on environmental impacts of foodservice and strategies that aim to improve the environmental sustainability of foodservice. Methods Eight electronic databases (ie, Cumulative Index to Nursing and Allied Health Literature Plus, Embase via Ovid, Global Health, National Health Service Economic Evaluation Database, Ovid Medline, ProQuest Environmental Science Collection, Scopus, and Web of Science) were searched from database inception to November 2018 for original research conducted across any stage of the hospital food supply chain (from production/procurement to waste management/disposal) that provides food/nutrition to patients, with no restrictions on language or study design. Titles/abstracts then full texts were screened independently by two authors. The Mixed Methods Appraisal Tool was used for quality appraisal for included studies. Data were synthesized narratively. Results From 29,655 records identified, 80 studies met eligibility criteria. Results were categorized into production/procurement (n=12), distribution (n=0), preparation (n=6), consumption (n=49), waste management/disposal (n=8), and multiple food supply chain aspects (n=5). The environmental impact most widely explored was food waste, with many studies reporting on food waste quantities, and associated economic losses. Strategies focused on reducing food waste by increasing patients’ intake through various foodservice models. Perspectives identified a shared vision for sustainable foodservices, although there are many practical barriers to achieving this. Conclusion The literature provides examples across the hospital food supply chain that demonstrate how environmental sustainability can be prioritized and evaluated and the opportunities for credentialed nutrition and dietetics practitioners to contribute. Future studies are warranted, particularly those measuring environmental impacts and testing the effects of sustainable strategies in the distribution, preparation, and waste management stages. J Acad Nutr Diet. 2020;(■):-.
Generated Summary
This systematic review investigates the environmental sustainability of hospital foodservices across the food supply chain, aiming to identify environmental and economic impacts, outcomes of improvement strategies, and perspectives of stakeholders. The review used a mixed methods approach, encompassing 80 studies from database inception to November 2018. The study design included both qualitative and quantitative research, focusing on hospital foodservice practices. Data were synthesized narratively across the food supply chain stages: production/procurement, distribution, preparation, consumption, and waste management/disposal, as well as multiple food supply chain aspects. The goal was to assess how hospitals can minimize their environmental footprint and contribute to a more sustainable food system, with a particular emphasis on the role of nutrition and dietetics professionals.
Key Findings & Statistics
- A total of 80 studies met the eligibility criteria.
- Studies were published between 1945 and 2018, with 52 out of 80 published during the past 10 years, since 2008.
- The majority of studies (n=48) satisfied all applicable MMAT quality criteria, indicating stronger study quality.
- The remaining 32 studies had one or more no or not reported responses to the quality criteria.
- The most widely explored environmental impact was food waste, with many studies reporting on food waste quantities, and associated economic losses.
- Production/procurement studies (n=12) captured where and how food is produced and the procurement practices of hospitals.
- Preparation studies (n=6) investigated the stage where food is prepared before patient consumption and after food is procured.
- Consumption studies (n=49) assessed the systems and methods that prepare and serve food to patients.
- Waste management studies (n=8) identified the management and disposal of foodservice waste produced in previous steps of the food supply chain.
- Multiple stage studies (n=5) referred to those that covered two or more stages of the food supply chain or exploration of sustainable food.
- A study of plate waste across multiple studies showed a range from 6% to 42%.
- Regarding meals, breakfast was reported to be least commonly wasted in several studies.
- Several studies reported on quantity of plate waste, an average of 447 g/patient/day, which ranged from 70 to 953 g/patient/day.
- Several studies estimated the economic cost of this food waste ranging from $1.7 to $4.4 for plate waste per patient/day and $90,960 to $342,449 per year.
Other Important Findings
- Strategies focused on reducing food waste by increasing patients’ intake through various foodservice models.
- Perspectives identified a shared vision for sustainable foodservices, although there are many practical barriers to achieving this.
- Strategies explored the impact of current procurement practices on the environment.
- A range of studies solely investigated a strategy (n=4) to enhance the sustainability of foodservice procurement, including local food procurement, farm to hospital initiatives, organic food, and sustainable meat procurement.
- The most commonly explored stage was the consumption stage.
- Strategies to improve consumption and decrease food waste, with 10 of them, the room service model, bedside electronic meal ordering system, Steamplicity, bulk food delivery, and isothermal trolleys.
- Studies that compared bulk trolleys to plated meal service showed a range of waste reduction.
Limitations Noted in the Document
- The study’s findings are limited by the variability in aims and outcomes of included studies, necessitating a narrative synthesis rather than a meta-analysis.
- The quality of the studies varied, with some lacking sufficient detail in methods, results, and sample characteristics.
- There was a lack of studies quantifying the environmental impacts of procured foods, especially the earlier stages of the food supply chain.
- The study only explored food provided to patients, not the broader commercial/retail foodservice in hospitals.
- The focus on the hospital setting may limit the generalizability of the findings to other healthcare settings or food service environments.
- The reliance on the search terms hospital OR hospitals might have potentially excluded other relevant studies, by excluding synonyms such as medical centers.
Conclusion
This systematic review underscores the significance of environmental sustainability in hospital foodservices and the need for comprehensive strategies across the food supply chain. The research reveals a widespread interest in sustainable practices, particularly related to food waste reduction and local food procurement. The findings show that, despite the shared vision for sustainable foodservices, there are practical barriers to achieving this vision. The evidence highlights that hospital foodservice systems have a substantial impact on the environment and offers valuable insights into the opportunities for change. A key aspect is that the literature demonstrates how environmental sustainability can be prioritized and evaluated across the hospital food supply chain. The review emphasizes the role of nutrition and dietetics practitioners in this endeavor, suggesting that their expertise can drive positive change and influence practices. The review also points to a need for further research, particularly in assessing the environmental impacts of food procurement and evaluating the effectiveness of sustainable strategies across various stages of the food supply chain, like distribution, preparation, and waste management. Future studies should quantify the environmental impacts of procured foods and assess the effectiveness of sustainable strategies at all stages of the food supply chain, particularly in the areas of distribution, preparation, and waste management, to further advance sustainability within hospitals. More collaboration and communication between stakeholders across the food supply chain, as well as government support through incentives, are necessary to make progress.