Environmental Sustainability of Hospital Foodservices across the Food Supply Chain: A Systematic Review

Supporting those experiencing food insecurity: A scoping review of the role of a dietitian

BACKGROUND

Increasing levels of food insecurity in the United Kingdom (UK) suggest an imperative to consider the role of dietitians in supporting people who may have insufficient access to safe and nutritious food.

OBJECTIVE

To explore the available evidence on the (i) role of a dietitian, (ii) impact of support and (iii) training needs of dietitians to support those with inadequate access to food.

METHODS AND DESIGN

Scoping review methodology was used to identify qualitative, quantitative and grey literature on the role of dietitians in supporting those with/or at risk of food insecurity. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used to report the evidence reviewed for this study. Methods included multiple literature searches, charting of data extracted, and content analysis. The data of interest included the country of study, study methodology, the population of interest, the role of a dietitian, the measures, tools or guidance used and a summary of key findings.

RESULTS

In total, 466 studies were identified, following the removal of duplicate records, 243 records were screened for inclusion; the full text of 95 articles was reviewed for eligibility, and 19 were included in the review. Articles were summarised descriptively using tables and synthesised to identify emerging themes. Overarching themes of dietitians' role included, (i) identification and screening of food insecurity, (ii) facilitating community interventions and (iii) policy development.

CONCLUSIONS

Dietitians hold a range of roles to support people at risk of or experiencing food insecurity. However, there are considerable gaps in current training programmes, and a paucity of evidence describing the impact dietitians have on improving nutrition outcomes for those individuals at risk of or experiencing food insecurity.

How Sustainable Are Hospital Menus in the United Kingdom? Identifying Untapped Potential Based on a Novel Scoring System for Plant-Based Provisions

BACKGROUND

Adopting plant-forward diets is essential for achieving climate targets. As the second-largest provider of public sector meals in the UK, the National Health Service (NHS) can significantly reduce its environmental impact by transitioning to plant-forward menus, contributing to its goal of being a net-zero healthcare service by 2045. This study evaluates the extent to which NHS hospitals currently align with sustainable practices by assessing the plant-forward nature of in-patient menus.

METHODS

Green Plans from 40 hospital trusts were analysed to assess commitment to plant-forward, lower-emission menus. Freedom of Information requests were sent to 50 NHS trusts, and 36 menus from the spring/summer season of 2024 were analysed. A novel scoring system was developed to assess the hospital menus, with subscores reflecting the availability of plant-based meals, ruminant-meat meals, and menu strategies to encourage plant-forward choices.

RESULTS

Green Plans showed limited commitment to increasing plant-based food options. Hospital menus scored poorly overall (average score of 20/100, range: 9-38). The lowest subscores were observed in the provision of fully plant-based meals and nudging techniques. The provision of ruminant meat varied (subscore range: 0-100) and all hospitals included processed meat on their menu. Hospitals with outsourced catering scored higher than those with in-house catering.

CONCLUSION

Despite national recommendations to shift towards plant-forward diets, NHS hospitals currently show little commitment and provide limited offerings in this regard. The novel scoring system offers a practical framework for monitoring progress and guiding hospitals towards environmentally sustainable, plant-forward menus.

A qualitative exploration of barriers, facilitators and best practices for implementing environmental sustainability standards and reducing food waste in veterans affairs hospitals

BACKGROUND

To improve the healthfulness of foods offered while accelerating the use of environmental sustainability practices, it is important to engage hospital food service operators in the adoption of such practices. The purpose of this study was to explore barriers, facilitators and best practices for implementing environmental sustainability standards in food service among veterans affairs (VA) hospitals in the United States.

METHODS

We conducted an online survey with 14 VA hospital food service directors and then 11 qualitative interviews. The survey assessed motivations for initiating sustainability standards and included a self-rating of implementation for each of five standards: increasing plant-forward dishes, procuring and serving sustainable foods that meet organic/fair trade and other certifications, procuring and serving locally produced foods, reducing food waste and reducing energy consumption. Interviews were transcribed verbatim. Qualitative analysis, including coding of themes and subthemes, was conducted by two coders to determine barriers, facilitators and best practices for each of these five standards. Quantitative methods (counts and frequencies) were used to analyse the survey data.

RESULTS

Participants had an average of 5 years of experience implementing sustainability standards. The top three motivators cited were reducing food waste, serving healthier foods and increasing efficiency or cost savings. Barriers revolved around patient preferences, contractual difficulties and costs related to reducing waste. Facilitators included taste testing new recipes that include more sustainable food options and easy access to sustainable products from the prime vendor. Best practices included making familiar dishes plant-forward and plate waste studies to prevent overproduction.

CONCLUSIONS

Although there were many barriers to implementation, food service directors had solutions for overcoming challenges and implementing food service sustainability standards, which can be tested in future sustainability initiatives.

Focus on patient perspectives in climate action policies for healthcare. A German survey analysis on what patients are willing to do

Background

The healthcare sector, while dedicated to improving health, paradoxically contributes significantly to global carbon emissions, accounting for approximately 4.9% of global emissions. Despite growing public concern about climate change, few studies have explored patients' awareness and attitudes toward the environmental impact of healthcare. This study aims to assess patients' perspectives on climate change and the sustainability of healthcare practices.

Methods

A cross-sectional survey was conducted at Ludwig-Maximilians-University (LMU) Hospital in Munich, Germany. Patients were invited to participate in a voluntary, anonymous online survey via strategically placed QR codes throughout the hospital. The survey explored patients' demographic information, environmental awareness, attitudes toward climate-friendly practices in healthcare, and willingness to support sustainable initiatives. Descriptive statistics and regression analyses were used to analyze the data.

Results

A total of 399 patients completed the survey (87% completion rate). The majority of respondents (92.3%) were aware of climate change, and 82.7% reported prioritizing climate-friendly practices in their personal lives. However, 55.9% of respondents were unaware of the healthcare system's contribution to carbon emissions, and only 18.3% knew about hospitals' climate impact. Despite this, 88.2% of respondents supported environmentally friendly initiatives in hospitals, and 86.5% were open to sustainable alternatives, provided that quality standards were maintained. Participants expressed significant interest in knowing the environmental impact of their treatments, with 63.2% in favor of a Nutri-Score-like system that would display the carbon footprint of medical procedures. Among those, 54.4% indicated that such a system would influence their choice of treatment. Similarly, 62.2% of respondents were interested in knowing the environmental impact of their medications, with 65% reporting that this information would affect their medication choices. A notable proportion of patients (66.2%) indicated willingness to support sustainable healthcare through shorter hospital stays and increased follow-up visits, while 35.8% were open to paying a CO2 compensation fee for their treatments. However, 81% were unwilling to pay higher insurance premiums to support environmentally friendly practices in hospitals. Regression analyses revealed that older age groups and having children were positively associated with environmental awareness (p < 0.05). However, factors such as gender, education level, relationship status, and illness severity did not significantly impact environmental attitudes. There was a significant correlation between patients' environmental friendliness and their readiness to take climate-protective actions (p < 0.001).

Conclusion

The study highlights a gap between patients' environmental awareness and their knowledge of healthcare's carbon footprint. While patients are generally supportive of sustainable practices in healthcare, their willingness to act diminishes when personal costs or discomfort are involved. A coordinated approach involving policy changes, patient education, and market innovations is essential to promote sustainable practices in healthcare without compromising patient care quality. Further research is needed to explore strategies for bridging the gap between environmental awareness and action in healthcare settings.

Quantifying hospital plate waste and identifying its correlates from patients' perspectives in Lebanon

Hospital plate waste poses a major challenge facing the present food systems, as providing meals that meet the nutritional requirements and expectations of the patients remains complex for hospital food services. This study aimed to assess the magnitude of plate waste in Lebanese hospitals, evaluate the patients' satisfaction levels, and identify the determinants of plate waste in participating hospitals. A cross-sectional study was conducted between April 2023 and September 2023, involving 155 in-patients from cardiovascular, gastrointestinal, obstetrics-gynecology, and surgical wards across 16 hospitals in different Lebanese governorates. Plate waste was measured, and patient satisfaction was assessed using a questionnaire. Plate waste represented 31.4% of the total food served, equivalent to 366 tonnes annually in the 16 participating hospitals. Waste was higher in hospitals located in rural areas (p-value = 0.771). The highest waste levels were observed in the obstetrics-gynecology ward and during lunchtime. Vegetables were the most wasted food group. The majority of participants were satisfied with the food service, and low appetite was the main reason for not consuming hospital meals. Food quality (β= -0.17, p-value = 0.049) and governorate (β= -0.18, p-value = 0.019) were determinants of plate waste. The hospital sector is as unique and challenging as other sectors regarding plate waste, which warrants further research to gain deeper insights into waste generation.

Forecasting the future of smart hospitals: findings from a real-time delphi study

BACKGROUND

In concert with other digital technologies, artificial intelligence (AI) is shaping the vision of smart hospitals. The transformation into smart hospitals, however, is all but trivial due to the lack of financial and human resources, digital skills, and supporting policies. Thus, the extent to which the vision of smart hospitals will eventually become reality is uncertain. In this context, our study provides a multidimensional conceptualization of the immediate future of smart hospitals to 2042.

METHODS

This study employs an iterative mixed-methods approach, including expert workshops and a Delphi study. We conducted a real-time Delphi study to forecast the evolution of smart hospitals in 5-year steps from 2027 to 2042. A total of 39 experts in healthcare, artificial intelligence, and management participated.

RESULTS

Our understanding of a technology-enabled smart hospital in this study includes four dimensions: artificial intelligence (AI), sustainability, ecosystems, and human-centeredness. Our findings underscore the critical need to address the shortage of hospital staff and general practitioners that models predict will peak by 2032. Additionally, our results show a significant shift to individualized medicine and home care. This shift indicates that smart hospitals are expected to leverage AI and digital technologies to tailor care to each patient. Furthermore, the roles and responsibilities of hospital staff will undergo significant changes. Healthcare personnel will have to adapt to new technologies that facilitate more efficient workflows and improve patient engagement in evolving healthcare environments. The results of our study suggest a shift in care to individualized medicine and home care, with corresponding changes in the roles and responsibilities of hospital staff who will employ new technologies.

CONCLUSIONS

The findings from our real-time Delphi study suggest that the vision of smart hospitals is gradually becoming reality over the next 20 years. Advancements in artificial intelligence should enhance operational efficiency and patient-centric care, while facilitating the integration of sustainability practices and fostering collaborative ecosystems. However, addressing challenges such as staff shortages, ethical considerations, and the need for robust digital skills will be essential. A deep pool of expert healthcare practitioners, clear ethical guidelines, and robust digital skills are essential to fully realize this vision and ensure that smart hospitals can meet the evolving needs of healthcare delivery.

The United European Gastroenterology green paper-climate change and gastroenterology

Climate change, described by the World Health Organization (WHO) in 2021 as 'the single biggest health threat facing humanity', causes extreme weather, disrupts food supplies, and increases the prevalence of diseases, thereby affecting human health, medical practice, and healthcare stability. Greener Gastroenterology is an important movement that has the potential to make a real difference in reducing the impact of the delivery of healthcare, on the environment. The WHO defines an environmentally sustainable health system as one which would improve, maintain or restore health while minimizing negative environmental impacts. Gastroenterologists encounter the impacts of climate change in daily patient care. Alterations in the gut microbiome and dietary habits, air pollution, heat waves, and the distribution of infectious diseases result in changed disease patterns affecting gastrointestinal and hepatic health, with particularly severe impacts on vulnerable groups such as children, adolescents, and the elderly. Additionally, women are disproportionally affected, since climate change can exacerbate gender inequalities. Paradoxically, while healthcare aims to improve health, the sector is responsible for 4.4% of global carbon emissions. Endoscopy is a significant waste producer in healthcare, being the third highest generator with 3.09 kg of waste per day per bed, contributing to the carbon footprint of the GI sector. Solutions to the climate crisis can offer significant health co-benefits. Steps to reduce our carbon footprint include fostering a Planetary Health Diet and implementing measures for greener healthcare, such as telemedicine, digitalization, education, and research on sustainable healthcare practices. Adhering to the principles of 'reduce, reuse, recycle' is crucial. Reducing unnecessary procedures, which constitute a significant portion of endoscopies, can significantly decrease the carbon footprint and enhance sustainability. This position paper by the United European Gastroenterology aims to raise awareness and outline key principles that the GI workforce can adopt to tackle the climate crisis together.

Food is Medicine Interventions and Climate Change

Food is Medicine (FiM), also known as Food as Medicine, integrates food and nutrition interventions into health care delivery with the primary goal to improve population health and address diet-related health conditions. To date, there has been little focus on the relation between FiM and climate change despite FiM's involvement with 2 key drivers of climate change: health care delivery and food systems. FiM may be able to advance lifestyle medicine and population health objectives, as well as mitigate some of the health care and food-related drivers of climate change, by focusing on 4 key areas: (1) Increasing the absolute number and proportion of patients who follow plant-based diets; (2) reducing food waste; (3) reducing unnecessary health care utilization; and (4) lowering transportation-related greenhouse gas emissions related to food procurement. Measuring the ecological impact of FiM alongside clinical, utilization, and financial measures will require a different analytical approach than that used traditionally in health care. Ultimately, thoughtful, data-driven, and urgent interventions that span the food and health care sectors are needed to sustainably support not only FiM, but human, environmental, and planetary health as well.

Evaluation of the Climate Impact and Nutritional Quality of Menus in an Italian Long-Term Care Facility

Global warming poses a significant threat to our planet, with the food sector contributing up to 37% of total greenhouse gas emissions. This study aimed to assess the climate change impact and healthiness of menus in a long-term care facility in Italy. We analyzed two 28-day cyclical menus using the carbon footprint (CF) and the Modified EAT-Lancet Diet Score (MELDS) to evaluate adherence to the Planetary Health Diet (PHD). Monte Carlo simulations were employed to explore 20,000 daily menu permutations. Results showed that the mean GHGEs of spring/summer and autumn/winter daily menus were 2.64 and 2.82 kg of CO2eq, respectively, with 99% of menus exceeding the 2.03 kg of CO2eq benchmark. Only 22% of menus were adherent to the PHD, with MELDSs ranging from 12 to 29. A strong inverse association between the CF and adherence to the PHD was observed. These findings suggest significant potential for reducing the CFs of meals served in nursing homes while promoting adherence to a planetary diet, presenting an opportunity to set new standards in caregiving and environmental sustainability.

Quantifying the locality of the food supply in a large healthcare organisation

AIM

Shocks to the food system (such as extreme weather events, wars, and pandemics) are felt by institutional food systems. For hospitals, these shocks affect the quantity, quality, and variety of foods that can be offered to patients. One strategy to buffer the hospital food supply from external threats is to prioritise ingredients produced locally. Thus, the aim of the current research is to describe the country of origin of all foods purchased by a large, metropolitan healthcare organisation and to identify opportunities for improving the locality of the food supply.

METHODS

This study was of a cross-sectional, observational design. The country of origin for all foods procured over a 1-year period by a large, urban healthcare organisation was determined by proportion of food budget spend. State of origin was identified for fresh fruit, vegetables, and meat. The organisation was in Queensland, Australia and utilised a cook-fresh, room-service foodservice model. Descriptive analysis was used to to determine the number of items and the proportion of budget spend on all foods produced in Australia, and by food category. Similar descriptive statistics were generated to determine the proportion of the budget spend on fresh fruits, vegetables and meats produced in Queensland.

RESULTS

Over the 1-year period, 659 individual food items were purchased by the hospital foodservice, and 502 food items were included in the anlaysis. In total, 53% of the food budget was spent on Australian foods (100% Australian ingredients) and almost all fruit (73%) and vegetables (91%) were Australian grown. Procuring fresh fruit (28%), vegetables (35%), and meat (46%) from within the state was less common, and this may reflect the primary states of production across Australia, and seasonal variability of the food supply.

CONCLUSIONS

Findings offer priority areas for improving the locality of the food supply. Future research to determine if procuring more foods locally has benefits to consistency of the food supply is warranted.

Green hospitals: Mitigating water footprint and greenhouse gas emissions through sustainable menu planning in Turkish state university hospitals

Considering the importance of sustainable nutrition, it is important that hospitals' meal menus are planned to ensure the lowest possible environmental footprint. In this study, we aimed to evaluate the environmental effects of hospital menus and the changes that may occur when these menus are planned according to the Turkey Dietary Guidelines and Mediterranean diet recommendations. In this context, first, the yearly environmental footprints of the standard meal menus of the state university hospitals in Turkey (n = 42), including water footprint (WF) and greenhouse gas emission (GHGE) values, were determined. Second, changes in the environmental footprint as a result of arranging the standard meal menus of state university hospitals according to the Turkey Dietary Guidelines and Mediterranean nutritional models were evaluated. It was determined that the average WF and GHGE values of hospital menus were 137,280 ± 18537.2 L/month and 140.0 ± 18.4 kg CO2-eq/month, respectively. Adjusting state university hospitals' standard meal menus according to Turkey Dietary Guidelines and Mediterranean nutritional models reduced WF by 24.8% to 103206.7 L/month and 37.8% to 85420.5 L/month, and GHGEs by 31.7% to 95.5 kg CO2-eq/month and 49% to 71.3 kg CO2-eq/month, respectively. In addition, it was determined that hospital meal menus planned according to the Turkey Dietary Guidelines and the Mediterranean nutritional model contained lower saturated fat and cholesterol and higher dietary fiber. In conclusion, planning hospital menus according to the Turkey Dietary Guidelines and Mediterranean nutritional recommendations can reduce the environmental footprint of hospital food services.

Sustainability-informed dietetics education: key messages for educators and national dietetics associations

BACKGROUND

Dietetics curricula currently fail to meet the educational needs of the future dietetic workforce to contribute expertise in sustainable, healthy food systems in the settings in which dietitians work. A 'Global Networking Event on Sustainable Food Systems in Nutrition and Dietetics Education' was held in June 2023 with the goals of building relationships among international stakeholders and informing the development of shared curricula.

METHODS

Plenary lectures, panels and roundtable discussions were held over 2 days, designed to provide the background required to generate informed actions. Topics included recent research from practice and education, competency standards and relevant policy documents, examples from the field, 'big questions' about scope and student perspectives. Key messages were summarised thematically to inform educators and national dietetics associations.

RESULTS

Fifty-five delegates attended from 11 nations representing education, research, dietetic associations, industry and diverse practice backgrounds. Key priorities identified for educators included co-development of curricular frameworks and pedagogical theory, practical training supports and solutions to limited time and expertise. Key recommendations for national dietetics associations included strategic promotion of sustainable food systems in dietetic roles and practical supports.

CONCLUSIONS

Outcomes are anticipated to stimulate ongoing discussion, collaboration and actions on sustainable food systems education within the dietetics profession leading to shared curricular models and supports.

Sustainability initiatives in inpatient psychiatry: tackling food waste

Background

Food plays a dual role in promoting human health and environmental sustainability. Yet, current food systems jeopardize both. Food waste poses a major global challenge due to its significant economic, social, and environmental impacts. Healthcare facilities generate the largest amounts of food waste compared to other forms of catering provision. Food waste correlates with environmental unsustainability and diminished patient satisfaction, compounding the prevalent challenge of hospital malnutrition and contributing to suboptimal patient outcomes.

Materials and methods

In a three-year interventional study (2020-2022) at a psychiatric tertiary care center, we assessed and mitigated food waste using evidence-based measures. We conducted systematic food wastage audits over three years (2020-2022) in May and June, each lasting four weeks. Costs were analyzed comprehensively, covering food, staff, infrastructure, and disposal. Environmental impact was assessed using Umweltbelastungspunkte (UBP) and CO2e/kg emissions, alongside water usage (H2O - l/kg).

Results

Economic losses due to food wastage were substantial, primarily from untouched plates and partially consumed dinners, prompting meal planning adjustments. Despite a >3% increase in meals served, both food waste mass and costs decreased by nearly 6%. Environmental impact indicators showed a reduction >20%. Vegetables, salad, and fruits constituted a significant portion of waste. Overproduction minimally contributed to waste, validating portion control efficacy.

Conclusion

Our study highlights significant economic and environmental losses due to hospital food waste, emphasizing the importance of resource efficiency. The strategies outlined offer promising avenues for enhanced efficiency. The decrease in food waste observed over the three-year period underscores the potential for improvement.

Implementation of sustainable food service systems in hospitals to achieve current sustainability goals: A scoping review

BACKGROUND

Food waste is a pivotal contributor to environmental degradation in the modern world. Vast amounts of food are wasted and many individual efforts and collective initiatives being underway to deal with this challenge. Hospitals are institutions that produce and provide food, but at the same time contribute greatly to food waste. The objective of this scoping review is to present available data regarding quantity of food waste generated in public hospitals and summarizes studies that assess and quantify the greenhouse gas emissions (carbon footprint) associated to food service management in hospitals.

METHODS

A systematic literature research was conducted by two qualified researchers in PubMed, Scopus, ISI Web of Science and Science Direct. The publication date was set to the last ten years, i.e., 2013-2023. All the abstracts retrieved were screened, and the eligible articles were selected after a two-step process. Abstracts from the retrieved full papers' references were also screened for eligibility. The selected papers were included in the final scoping review.

RESULTS

Overall, 2870 studies were identified and 69 were included in the review. Most of the studies (n = 33) assessed the causes and quantified the amount of food waste generated in hospitals. A small number of studies (5) estimated carbon dioxide equivalent (CO2-eq) produced by food waste. Although several studies suggested strategies and measures to reduce the environmental impact of foodservice operations, none of them implemented a comprehensive foodservice management system.

CONCLUSION

This scoping review suggests that hospital diets contribute to food waste and may have a negative environmental impact. There are several internal and external factors and practices that influence positively or negatively the sustainability of hospital food service systems. Systematic efforts are needed to identify and enhance parameters that could improve the environmental footprint of hospitals in terms of more effective management of food waste.

Diverting Food Waste From Landfill in Exemplar Hospital Foodservices: A Qualitative Study

BACKGROUND

The US Environmental Protection Agency Food Recovery Hierarchy suggests methods for diverting food waste from landfill. Knowledge of how hospital foodservices implement food waste management strategies could help modernize food waste practices.

OBJECTIVE

The aim of this study was to explore hospital staff members' experiences of implementing a food waste management strategy to divert food waste from landfill in their hospital foodservice, including the journey, challenges, and facilitators of this practice change.

DESIGN

A qualitative study was conducted in 2022-2023 using semi-structured interviews.

PARTICIPANTS/SETTING

Eighteen participants were staff members with knowledge of the food waste management strategy from 14 exemplar hospitals in United States, Spain, Scotland, and Australia using strategies to divert food waste from landfill within the last 10 years.

ANALYSES PERFORMED

Mapping and thematic analysis were undertaken to code and identify themes from the interviews that described staff members' experiences of the journey to implement the strategy.

RESULTS

Six hospitals donated food, 1 transferred food waste for animal feed, 4 used an industrial solution, and 3 sent food waste for composting. A common journey pathway for successful implementation was identified from participants' experiences. It features the following 6 phases: idea, preparation, roll out, maintenance, established practice, and evolution. Facilitators included legislation, enthusiastic staff members, executive support, and "luck." Challenges were smells, occasions when food waste was not collected, equipment breakage, and funding depletion.

CONCLUSIONS

This study identified a common journey pathway for implementing a food waste management strategy in hospital foodservices that can be used to anticipate and prepare for the steps in the implementation process.

The role of the health sector in tackling climate change: A narrative review

Climate change is one of the largest threats to population health and has already affected the ecosystem, food production, and health and wellbeing of populations all over the world. The healthcare sector is responsible for around 5 % of greenhouse gas emissions worldwide and can play a key role in reducing global warming. This narrative review summarized the information on the role of healthcare systems in addressing climate change and strategies for reducing its negative impact to illustrate different types of actions that can support the ecological transformation of healthcare systems to help reaching sustainable development goals. A wide range of green interventions are shown to be effective to reduce the carbon footprint of healthcare and can have a meaningful impact if implemented systematically. However, these would not suffice unless accompanied by systemic mitigation strategies altering how healthcare is provided and consumed. Sustainable healthcare strategies such as reducing waste and low-value care will have direct benefits for the environment while improving economic and health outcomes. The healthcare sector has a unique opportunity to leverage its position and resources to provide a comprehensive strategy for fighting climate change and improving population health and the environment on which it depends.

Hospital food management: a multi-objective approach to reduce waste and costs

Food waste contributes significantly to greenhouse emissions and represents a substantial portion of overall waste within hospital facilities. Furthermore, uneaten food leads to a diminished nutritional intake for patients, that typically are vulnerable and ill. Therefore, this study developed mathematical models for constructing patient meals in a 1000-bed hospital located in Florida. The objective is to minimize food waste and meal-building costs while ensuring that the prepared meals meet the required nutrients and caloric content for patients. To accomplish these objectives, four mixed-integer programming models were employed, incorporating binary and continuous variables. The first model establishes a baseline for how the system currently works. This model generates the meals without minimizing waste or cost. The second model minimizes food waste, reducing waste up to 22.53 % compared to the baseline. The third model focuses on minimizing meal-building costs and achieves a substantial reduction of 37 %. Finally, a multi-objective optimization model was employed to simultaneously reduce both food waste and cost, resulting in reductions of 19.70 % in food waste and 32.66 % in meal-building costs. The results demonstrate the effectiveness of multi-objective optimization in reducing waste and costs within large-scale food service operations.

Nurses' Environmental Practices in Northern Peruvian Hospitals

BACKGROUND

Decreasing emissions of the global healthcare sector will be an important tool for decreasing the magnitude of climate change. The environmental practices of nurses can have a positive environmental impact. The purpose of this study is to identify environmental practices performed by nurses while at work and home along with their associated factors.

METHODS

This study is a cross-sectional descriptive study conducted by surveying nurses from two public hospitals in Lambayeque, Peru. We utilized the Nurses' Environmental Awareness Tool to collect information about nurses' knowledge on environmental impacts, their risk to health, and environmental behaviors at both work and home.

RESULTS

Of the 106 participants who responded, the average age was 41 years, and 29 (28%) worked in surgical services. A little more than half of nurses reported appropriate energy use (51%) and recycling (53%) at work, while 94 (89%) implemented environmental biosafety. There was an observed association between age and years of employment with appropriate energy use, recycling, implementation of environmental biosafety, appropriate chemical substance use, and preventing medication waste.

CONCLUSION

Nurses reported a favorable tendency toward adequate environmental practices at work and at home. However, more studies are needed to identify the factors that increase nurses' use of these practices.

APPLICATIONS TO PRACTICE

As one of the most trusted professions, professional nurses have an opportunity to play a pivotal role in promoting environmental health and practices in both the workplace and their personal lives. This study highlights areas of potential intervention in the workplace to develop and promote appropriate environmental practices by nurses to decrease pollution by the healthcare sector.

Characterizing food environments of hospitals and long-term care facilities in the Netherlands: a mixed methods approach

BACKGROUND

Hospitals and long-term care facilities, which are key institutions to serve health and well-being, have an important exemplary role in providing supportive food environments to encourage healthy and sustainable food choices. The objective of this study is to characterize the physical, socio-cultural, political and economic dimensions of the food environment for health care receivers, health workforce and visitors in healthcare settings, and make comparisons between the food environment of hospitals and long-term care facilities.

METHODS

To characterize the food environment in healthcare settings, two sub-studies were conducted. In sub-study 1, semi-structured interviews were held with staff members (n = 46) representing 11 hospitals and 26 long-term care facilities (rehabilitation centres, nursing homes, institutions for people with intellectual disabilities and mental healthcare institutions). In sub-study 2, staff members audited the food environment in hospitals (n = 28) and long-term care facilities (n = 36) using a predefined checklist.

RESULTS

The food environment in Dutch healthcare settings varies substantially between locations although noticeable differences between hospitals and long-term care facilities were identified. Hospitals and larger long-term care facilities featured more often restaurants and utilized central spaces for preparation of meals, while smaller long-term care facilities often operated as household-like settings. Type of healthcare shaped the socio-cultural food environment, with hospitals primarily emphasizing nutrition for fast recovery, while long-term care facilities more often as an instrument (i.e., to structure the day). Participants highlighted the importance of food policies and broad organizational support for realizing and regulating improvement of the food environment. Yet, long-term care facilities were less familiar with national guidelines for food environments compared to hospitals. Several economical aspects, like profit motives, strict budgets and contracts with external parties affected and shaped the food available within all healthcare settings.

CONCLUSIONS

This study characterized the food environment in Dutch healthcare settings. Disclosed differences between hospitals and long-term care facilities should be incorporated in strategies for a transition of the food environment. Future research should investigate the underlying mechanisms of the healthcare food environment attaining all healthcare stakeholders - health care receivers, staff and visitors - while prioritizing sustainability alongside healthiness.

Barriers and enablers to implementing environmentally sustainable practices in healthcare: A scoping review and proposed roadmap

This scoping review sought to identify the barriers and enablers to implementing environmentally sustainable practices in healthcare, as well as propose a multi-phased approach to enable such implementation. The three concepts guiding the search were (1) environmental sustainability; (2) healthcare; and (3) barriers or enablers. The PRISMA checklist for scoping reviews was used to guide this search. A total of 16 articles were included and reviewed for data extraction. While most articles focused on healthcare in general, dentistry and surgery were the most recurring clinical areas of focus. Barriers and enablers were related to the individual (e.g. knowledge, skills, and attitude), institutional (e.g. budget, strategy, and readiness), geographical/infrastructural (e.g. infrastructure and public awareness), political (e.g. regulations and incentives), and other (e.g. patient awareness and knowledge). A key enabler identified was having transformational leadership with a clear vision and collaborative approach.

Applying the theoretical domains framework and behavior change wheel to inform interventions for food and food-related waste audits in hospital foodservices

Background

Completing aggregate food and food-related waste audits in hospital foodservices is an intense practice, however they can demonstrate problem areas that require attention to reduce waste. Identifying interventions to facilitate and improve the implementation of these audits can be guided by behavior change science. The aims of this study were to use behavior change theories and frameworks to (1) describe the drivers of behavior to complete food and food-related waste audits and (2) identify possible interventions that support the implementation and uptake of these audits.

Methods

Purposive sampling was used to recruit participants from hospitals in Victoria, Australia who worked in their foodservice system. Semi-structured interviews sought knowledge of participant's perceived barriers and enablers to completing food and food-related waste audits. Deductive analysis using the Theoretical Domains Framework (TDF) and Capability Opportunity Motivation Behavior theory (COM-B) identified dominant drivers of behavior. TDF domains were then matched to their corresponding intervention functions according to the Behavior Change Wheel framework (BCW) to identify relevant strategies that may support audit implementation.

Results

Data from 20 interviews found the dominant COM-B constructs (TDF domains) were psychological capability (knowledge, skills), physical opportunity (environmental context and resources), and reflective motivation (social/professional role and identity, beliefs about capabilities). These dominant domains come from narratives that participants shared about foodservice staffs' lack of knowledge, labor, time, and the hospital avoiding responsibility for audit completion. Corresponding intervention functions that could have the most potential for implementing waste audits were education, training, environmental restructuring, modeling, and enablement. Participants' shared perspectives of audit enablers resembled these: for example, obtaining staff buy-in, reinforcing behavior through incentives and installing an audit champion.

Conclusion

To transition toward regular food and food-related waste auditing practices in hospital foodservices these findings may help identify practice and policy change that delivers standardized auditing activities to encourage long term behavior change. Interventions to support audit completion should address each behavioral construct and relevant domain, as individual hospital sites will experience unique contextual factors and expectations influencing audit outcomes. A co-design process that includes staff and stakeholders of hospital foodservices is recommended to enable engagement and practical solutions to audit implementation.

The role of policy in supporting environmentally sustainable foodservice in healthcare: lessons from exemplar hospitals

Background

Foodservice in hospitals contributes to the environmental footprint of healthcare delivery. There is little known about the role of policy in supporting environmentally sustainable foodservices. The aim of the study was to explore policy in exemplar environmentally sustainable hospital foodservices from the perspective of hospital staff, toward what makes a policy effective, the limitations of policy, and the influential levels and types of policy.

Methods

A generic qualitative inquiry approach was utilized. Staff involved in foodservices were interviewed about the role of policy during 2020-2021 from 14 hospitals across nine countries. Data were analyzed using framework and thematic analysis.

Results

Policies spanned across high level policies at the level of the healthcare organization, local hospital procedures and protocols, as well as public policy from local, state/provincial and national government. Internal organizational policy was used to embed practices within the organization in the long term and help to build a shared vision and goal where public policy had lacked guidance. The creation, content and methods of communication and creating accountability made internal organizational policy successful. Public policy was most effective when it was mandatory, had clearly defined targets and funding to assist implementation. These exemplar hospitals also demonstrated attributes of policy entrepreneurs by engaging with policy makers to share their stories and lobby government for policy change.

Discussion

Policy from within the healthcare organization is an important mechanism for enabling hospitals to deliver and maintain environmentally sustainable foodservice. Public policy must be designed considering the unique implementation challenges hospitals face to ensure they are successful.

A Review of the Applicability of Current Green Practices in Healthcare Facilities

BACKGROUND

Circular economy (CE) has raised great interest as a concept and as a development model worldwide. This concept aims to provide a substitute for the linear economic model, which was based on production and consumption, continuous growth, and resources depletion. CE allows a greener economy with sustainable development and promotes more balanced societies. The healthcare sector is a major contributor to the climate crisis, with a carbon footprint representing 4.4% of global net emissions. It is thus essential to rethink the applicability of CE in healthcare.

METHODS

We conducted a scoping review guided by the Arksey and O'Malley methodological framework and utilised PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist. A systematic search from MEDLINE complete, SCOPUS, and Web of Science databases published between 1992 and 2022.

RESULTS

Through database searching a total of 1018 records were identified and 475 duplicates were removed. From the total search, 543 articles were screened by title/abstract according to the inclusion and exclusion criteria. After screening, 38 full-text articles were selected and assessed for eligibility. Forty-seven additional records were also identified through other sources and screened for eligibility. Other sources included: 12 articles from snowballing of previous papers; 9 articles following peer-reviewers suggestions; 19 reports from relevant organisations in CE and healthcare; two webpage, and one book.

CONCLUSION

Specific areas were identified where hospitals could reduce their greenhouse gas (GHG) emissions and consequently their negative environmental impact, namely through waste management, energy, water, transportation/travel, hospital design, food optimisation, green procurement, and behaviour. Also, lack of staff awareness and knowledge of the environmental impact of healthcare, and hospitals sustainability were identified as major contributors.

'It's a constant changing environment, and we're just playing catch up': Hospital food services, food waste, and COVID-19

AIMS

Hospital food service operations have been affected by the COVID-19 pandemic, particularly resulting in increased waste. The aim of this research was to explore the impact of the COVID-19 pandemic on hospital food services, particularly on food waste and the completion of food waste audits.

METHODS

A qualitative interview research design was used. Semi-structured interviews were completed and recorded via Zoom, focusing on the barriers and enablers towards the completion of hospital food waste audits. Twenty-one participants were interviewed from 12 hospitals. No questions were related to the COVID-19 pandemic and its impact on hospital food services, however this issue frequently emerged during interviews. Data were coded following inductive thematic analysis.

RESULTS

Five themes were generated from the interviews related to COVID-19 and hospital food services; impacts on practice, labour, change, technology and post-pandemic expectations. Participants reported COVID-19 negatively affected food service operations. Changes included increased food waste, contact restrictions, and labour shortages. Nonetheless, hospitals embraced the challenge and created new positions, trialled different food waste data collection methods, and utilised technology to support food service operations around COVID-19 restrictions.

CONCLUSIONS

Despite the impact COVID-19 had on hospital food services, including their ability to audit food waste and increased food waste generation, the response from food services has demonstrated their adaptability to change. Sustainable healthcare, including the aggregate measuring and reduction of food waste in hospital food services, is an essential transition post-pandemic, and may be facilitated through the operational changes forced by COVID-19.

Transformative systemic changes to embed environmental sustainability in foodservices: A grounded theory exploration

AIMS

Foodservices are a strong contributor to global environmental impact. Systemic change is required to lead the transformation towards environmentally sustainable foodservices. However, guidance to support foodservices to be more environmentally sustainable is lacking. The aim was to explore food-related environmentally sustainable strategies and their transferability to foodservices in a range of settings, to inform a framework for future application and research.

METHODS

A constructivist grounded theory study design was used. Semi-structured interviews with foodservice sustainability consultants, who support foodservice organisations to improve environmental sustainability, were conducted. Interviews were recorded, transcribed, and coded line-by-line. Ten consultants were purposively sampled for diversity in location, organisation type, funding model, and services provided. Codes were collapsed into categories, to inform the development of themes and a framework for the implementation of strategies.

RESULTS

Four sub-themes were created under an overarching theme of 'Transforming the Foodservice System': embedding leadership, shifting perspective, constructing collaborative networks, and fostering momentum. A range of implementation strategies were captured within the sub-themes.

CONCLUSION

These themes informed the development of a practical application framework for implementing sustainable strategies in foodservices that is useful for practice and future research in the area.

The origins of hospital food: Where does it come from and what do staff, patients and suppliers think about local food?

AIMS

To identify the origin of fresh and minimally processed foods served to hospital patients, and explore the challenges and enablers to local food procurement in hospitals.

METHODS

A mixed methods study was conducted in a healthcare network in Victoria, Australia. Packaging labels and product information were used to audit fresh and minimally processed foods purchased in 1 week. Processed food items and meals made offsite were not audited. Interviews were conducted with patients, staff and suppliers to explore their perspectives towards local food in hospitals. Framework analysis was used to identify themes.

RESULTS

Of 105 food products audited, 32% were imported, 25% were 'local' from Victoria and the remaining 43% were from within Australia (excluding Victoria). Qualitative interviews revealed several challenges including: increased cost of local food items, inconsistent supply and variable quality of local produce, difficulty accessing origin information, and lack of autonomy for hospitals to make food procurement choices. Enablers included: conducting a food origin audit to increase awareness, group purchasing organisation prioritising local food suppliers, and suppliers valuing local produce.

CONCLUSION

A food origin audit and interviews with stakeholders provided a rich understanding of current practices and how to increase local food procurement.

Approaches to Greening Radiology

The health care sector is a resource-intensive industry, consuming significant amounts of water and energy, and producing a multitude of waste. Health care providers are increasingly implementing strategies to reduce energy use and waste. Little is currently known about existing sustainability strategies and how they may be supported by radiology practices. Here, we review concepts and ideas that minimize energy use and waste, and that can be supported or implemented by radiologists.

How to improve food waste management in hospitals through focussing on the four most common measures for reducing plate waste

Hospitals have a responsibility to link human health and the environment, but food waste in hospitals has traditionally been much higher than in other areas of food supply. The cause of this situation has many negative impacts on health, economy, society, and environment. As a result, food waste has become a topic of discussion in hospital food departments. Part of this problem is plate waste, the served food that remains uneaten by patients. Given the magnitude of the food problem, this systematic review is aimed to identify the most common measures used to reduce plate waste in hospitals. PubMed, Scopus, and Google Scholar databases were comprehensively searched to identify food waste studies worldwide using related search terms. Many approaches have been recommended to increase patient food intake and minimise plate waste in hospitals. Up to date, the four most common include flexible portion sizes, increased food choices through selective menus, additional nutritional support and a better ordering and delivery system. Among them, the most used and effective are flexible portion sizes which may increase the ability of patients choosing their menus and upgrade ordering and delivery system by electronic format. In most studies, plate waste covers the most significant percentage of food waste produced in hospitals, while more than one approach is recommended to minimise it. In this aspect, further well-design, multicenter, clinical studies are strongly required to highlight and establish novel and effective approaches for improving food waste management in hospitals by reducing plate waste.

Quantifying waste and its costs in hospital foodservices

AIM

To measure the amount of different types of food and food packaging waste produced in hospital foodservice and estimate the cost associated with its disposal to landfill.

METHOD

A foodservice waste audit was conducted over 14 days in the kitchens of three hospitals (15 wards, 10 wards, 1 ward) operating a cook-chill or cook-freeze model with food made offsite. The amount (kg) of plate waste, trayline waste and packaging waste (rubbish and recycling) was weighed using scales and the number of spare trays and the food items on them were counted. Waste haulage fees ($AU0.18/kg) and price per spare tray item were used to calculate costs associated with waste.

RESULTS

On average there was 502.1 kg/day of foodservice waste, consisting of 227.7 kg (45%) plate waste, 99.6 kg (20%) trayline waste and 174.8 kg (35%) packaging waste. The median number of spare trays was 171/day, with 224 items/day on them worth $214.10/day. Only 12% (20.4 kg/day) of packaging waste was recycled and the remaining 88% (154.4 kg/day) was sent to landfill along with food waste at two hospitals. Overall 347.3 kg/day was sent to landfill costing $62.51/day on waste haulage fees, amounting to 126.8 tonnes and $22 816.15 annually.

CONCLUSION

A substantial amount of waste is generated in hospital foodservices, and sending waste to landfill is usual practice. Australia has a target to halve food waste by 2030 and to achieve this hospital foodservices must invest in systems proven to reduce waste, solutions recommended by policy advisors (e.g., waste auditing) and waste diversion strategies.

Institutional pressures for SDGs in Indian food supply chains

Purpose

This paper aims to analyze the influence of institutional pressures on Indian Food Supply Chain (FSC) actors’ intention to adopt strategies for Sustainable Development Goals (SDGs). By focusing on an agrarian state, this paper explores the prioritizations of SDGs by FSC actors and analyzes the relative impact of institutional pressures in adopting strategies for SDGs.

Design/methodology/approach

Quantitative data was collected using questionnaires from 303 respondents engaged in the food industry in an agrarian state in India.

Findings

The SDG prioritizations of FSC actors are evidenced using SDG models, thereby suggesting the presence of tradeoffs and synergies within SDGs in FSCs. By using institutional theory, this study defines the impact of sustainability drivers on Indian FSCs, and contrary to previous studies, normative institutional pressures are found not significant – this paper explicates the reasons for this.

Originality/value

Differing stakeholder groups and their prioritizations can result in ranking one SDG over another, thereby resulting in SDG tradeoffs. Such tradeoffs imply that the achievement of one SDG could negate the achievement of another SDG, and therefore, this study explicates the need for a holistic managerial approach to adopting SDGs.

Factors influencing implementation of food and food-related waste audits in hospital foodservices

BACKGROUND

Designing a food waste audit tool for novel hospital foodservice practice does not guarantee uptake. Intended users must be consulted to understand the tool's feasibility and face validity. This study aimed to identify the perspectives of staff involved in the operation of hospital foodservices on (1) how an evidenced based consensus pathway food waste audit tool is perceived to translate into practice, and (2) to determine the factors that influence the completion of food and food-related waste audits within this setting.

MATERIALS AND METHODS

Purposeful sampling was used to recruit staff with knowledge on the operation/governance of foodservices within hospitals in Victoria, Australia. Semi-structured interviews (n = 20) were conducted via Zoom to explore barriers and enablers to completing food and food-related waste audits and a previously published food waste audit tool. NVivo was used for inductive thematic analysis.

RESULTS

Three factors determined the completion of food and food-related waste audits in hospital foodservices, and each factor could be a barrier or an enabler; (1) capacity: the availability of time, labour and materials to complete an audit (2) change: staff resistance to audit procedures and how to gain their buy-in (3) processes, governance, and leadership: the opportunity for high level support, policy and structure to encourage waste audits if present. The consensus tool appeared to have face validity. Planning audit operations, conducting stakeholder meetings, providing education/training to foodservice team members, and facilitating communication between managers and staff were described to support consensus tool use and audit completion.

CONCLUSION

The consensus tool can be used to support hospital foodservices to complete food and food-related waste audits, although it may need to be customised to be fit for purpose. Optimising the capacity, change management and processes, governance and leadership of the foodservice department may improve the experience and success of a food and food-related waste audit.

Innovation in Healthy and Sustainable Food Product Development for Health and Aged Care: A Scoping Review

Population ageing and climate change are issues of global concern. Subsequently, the need for healthy and sustainable food systems to meet the increasing demands for health and aged care is evident. This review aimed to systematically identify studies reporting new or innovative foods, drinks and snack products in health and aged care, and describe health and environmental sustainability considerations where reported. Methods were guided by the Joanna Briggs Institute guidelines for scoping reviews and reported against the PRISMA-ScR guidelines. Eligible studies were conducted in an inpatient healthcare setting or aged care facility where a new or innovative food, drink or snack product was evaluated with outcomes of product use, acceptability, cost, appropriateness for the population, and clinical or environmental sustainability outcomes in the last decade. Three databases were searched using a replicable strategy, with five publications of four studies included in the final library. Product innovations were led at the facility level and included testing dewaxed brown rice, talbinah, and an apple/pear juice fibre solution. Results suggest that food industry suppliers are operating in parallel with foodservices within hospital and aged care. Future intersection would be transformative for both industry sectors.

Foodservice systems and mealtime models in rehabilitation: Scoping review

AIMS

To describe current foodservice systems and mealtime care utilized in the rehabilitation setting. A secondary aim was to identify commonly used outcome measures in foodservice research in the rehabilitation setting.

DESIGN

A scoping review.

DATA SOURCES

PubMed, CINAHL, Scopus, Embase, PsycINFO and Cochrane were searched until January 2022.

REVIEW METHODS

The review was conducted according to Joanna Briggs Institute's methodology for scoping reviews. Included studies were conducted in the inpatient rehabilitation setting, adult population ≥18 years old and provided a description of at least one element of the foodservice system, food and menu, waste and/or eating environment.

RESULTS

Of 5882 articles screened, 37 articles were included, reporting 31 unique studies. Most rehabilitation units had cook-fresh production methods (50%), used decentralized bulk delivery methods (67%) had a communal dining room (67%) and had a 3-week menu cycle (71%). Mealtime care was predominantly provided by nursing staff, however few studies reported on specific activities. Nutritional intake was a key outcome measure across included studies (43%), with only six papers reporting on rehabilitation outcomes. Of the intervention studies (n = 9), all were aimed at improving nutritional intake through menu or mealtime care modifications; few (n = 3) studied changes in rehabilitation outcomes.

CONCLUSION

This scoping review identified a considerable lack of reporting of foodservice and mealtime care systems used in rehabilitation settings in the available literature. Further investigation is required to understand what models of mealtime care are provided to patients and to understand the impact of changes to foodservice and mealtime systems on patient outcomes.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was necessary for this review.

Food and food-related waste management strategies in hospital food services: A systematic review

AIM

This review explored peer-reviewed and grey literature to describe the types and characteristics of food or food-related waste management strategies used in hospital food service settings; their financial, environmental and staffing outcomes; and the barriers and enablers associated with their implementation.

METHODS

Six electronic databases, 17 Google Advanced searches, and 19 targeted websites were searched for peer-reviewed and grey literature. Literature reporting the financial, environmental, or staffing outcomes of food or food-related waste management strategies that reused, recovered energy from, or recycled waste instead of sending it to landfill were eligible. Document screening and review were completed in duplicate, and included peer-reviewed literature were assessed for quality using the Mixed Methods Appraisal Tool. Data were synthesised narratively.

RESULTS

Four peer-reviewed and 81 grey literature records reported 85 strategies. When grouped from most to least favourable according to the food recovery hierarchy they managed waste by: donating surplus food (n = 21); feeding animals (n = 2); industrial use (n = 11); composting (n = 34) and other (n = 17). These approaches had the capacity to reduce waste hauling fees (n = 14), reduce staff handling of waste (n = 3), and decrease the amount of waste sent to landfill (n = 85). Barriers included contamination of waste streams, while enablers included leadership and time-neutral changes.

CONCLUSION

This review summarises the waste management strategies used by hospitals worldwide that divert food and food-related waste from landfill, their outcomes, and position in the food recovery hierarchy to enable hospital food services to implement appropriate practice and policy changes to decrease their environmental footprint.

Sustainable Development Goals: a review of SDG 12.3 in food supply chain literature

Purpose

Food Loss and Waste (FLW), a result of non-sustainable consumption and production, has significant socio-environmental impacts and is addressed in the United Nation's Sustainable Development Goal (SDG) 12.3. To address current research on FLW and SDG 12.3, the authors aim to evidence the current state of knowledge on drivers and barriers to SDG 12.3 through a comprehensive literature review.

Design/methodology/approach

The authors employed a multi-step systematic literature review process and retrieved 171 studies addressing SDGs, with 83 explicitly addressing SDG 12.3. The analysis involved a qualitative content analysis of studies retrieved by analyzing key findings and relationships between drivers and barriers to FLW.

Findings

While academic research focuses on SDG 12.3 by stressing the necessity of FLW reduction, it fails to explain the drivers and barriers to minimizing FLW. The authors developed a conceptual framework to demonstrate how barriers and drivers can inhibit or stimulate the dynamics that will achieve SDG 12.3 through effective planning and management.

Research limitations/implications

This study addressed the theoretical limitations of existing studies and clarified the critical gaps in the current literature, thereby guiding future researchers in the food supply chain (FSC) context.

Originality/value

The research to date focused on high-income countries, and future empirical studies should focus on consumption patterns, the associated drivers and barriers of food waste in low-income countries and its social impact.

Harnessing the pillars of institutions to drive environmentally sustainable hospital foodservices

Background

The cultural-cognitive, normative and regulative pillars of institutions influence the ability of hospitals to change how they function at an organizational and operational level. As more hospitals and their foodservices instigate changes to address their environmental footprint and impact on food systems, they move through the “sustainability phase model” from no response through to high level action and leadership. The aim of this study was to describe and compare the pillars of institutions between hospitals in different stages of achieving environmentally sustainable foodservices (business-as-usual vs. exemplar hospitals).

Methods

For this qualitative inquiry study, interviews were conducted with 33 hospital staff from 3 business-as-usual hospitals in Melbourne, Australia and 21 hospital staff from 14 exemplar hospitals across 9 countries. Participants were asked questions about their perspectives on environmental sustainability in foodservices and the barriers, enablers and drivers they experienced. Each data set was analyzed thematically and then compared.

Findings

There was a clear and distinct difference in responses and behaviors within each pillar between the exemplar and business-as-usual hospitals. The cultural-cognitive pillar identified a similarity in personal belief in the importance of addressing environmental impacts of foodservices, but difference in how staff saw and acted on their responsibility to drive change. The normative pillar uncovered a supportive culture that encouraged change in exemplar hospitals whilst business-as-usual hospital staff felt disheartened by the difficult processes and lack of support. The regulative pillar reflected business-as-usual hospital staff feeling restricted by government policy vs. exemplar hospital participants who were motivated to internalize government policy in different ways and work with other hospitals to advocate for better policy.

Interpretation

These findings highlight strategies related to each of the three pillars of institutions that can be used to drive effective, sustainable long term change within hospitals. This includes staff education and training, revisiting hospital culture and values around environmental sustainability, embedding sustainable foodservices in internal policies, and a comprehensive government policy approach to sustainable healthcare.

Mapping the Roles of Nutrition and Dietetics Professionals in Sustainable Food Systems and Exploring Opportunities for Strategic Collaboration

Current food systems drive environmental damage, social injustices, and undermine health, and these challenges are complex and seemingly intractable. Collaboration is required to transition to more sustainable food systems (SFS). Registered Dietitians and Nutritionists (RDs) are an under-leveraged and well-positioned group to contribute to addressing food systems challenges because of their locations in the system and their existing skillsets. Drawing on research with dietitians, this perspective paper presents both a theoretical proposal as well as collective expertise in supporting sustainable development of the global food system. It highlights where RDs work in food systems with the aim to reveal multiple points of entry where RDs can and do contribute to SFS across food systems, approaches to apply, as well as opportunities for collaboration within and beyond the profession. Educational and societal barriers exist that prevent systematic RD engagement; however, examples of established work provide models to follow.

Adopting Sustainable Menu Practices in Healthcare Institutions: Perceived Barriers and Facilitators

Purpose: The healthcare sector is an important area for sustainable food initiatives, given its inherent mission to heal and its substantial impact on the food system. Foodservice managers can take part in these initiatives by using sustainable menu practices (SMPs). This study aimed to explore managerial perceptions of barriers and facilitators to adopting SMPs in Québec healthcare institutions.Methods: Seventeen foodservice managers were recruited through purposeful sampling to participate in a qualitative semi-structured interview. The Diffusion of Innovations theory was used to assess the main determinants of the diffusion of an innovation (SMPs) through a complex social system (healthcare organization).Results: Participants reported more barriers than facilitators. Lack of support at many levels was recognized as a major hindrance to SMP adoption, as were shortfalls in political directives. Increased collaboration between all food system actors and better communication in healthcare were perceived as needed for increased SMP adoption.Conclusions: This research contributes to an in-depth understanding of managerial experiences in SMP adoption in various regional and healthcare settings. Findings suggest the need for support and strategies that would remove important barriers for foodservice managers and contributed to the development of a guide to support foodservice managers in implementing SMPs.

The Origins of Food Supplied to an Australian Public Hospital

Local food procurement by public institutions such as hospitals offers multiple benefits including stimulating the local economy, creating jobs, and building resilience within the food supply. Yet no published study has attempted to quantify the local food purchase by hospitals. This baseline is needed to identify gaps, set targets, and monitor change. The objective of this study was to investigate the origin of food supplied to a metro tertiary public hospital and to describe the proportion of food budget spent on items with ingredients grown in Australia and “locally” within the state of Victoria. Food procurement data were collected and analyzed during October 2020-April 2021. All items purchased by the cook fresh kitchen supplying meals to inpatients and two childcare centres during an 8-day menu cycle period were audited. Following an inspection of food packaging labels to determine country of origin, data on the proportion of Victorian content were collected from manufacturers and suppliers of foods containing Australian ingredient. Almost 80% of the food budget (AU $17,748 and 200 items) was spent on items containing significant (at least 75%) Australian content, while 11% was spent on entirely imported foods. The specific geographic origins of 55% of the budget spent on “Australian” food remain unknown as information from manufacturers and suppliers was not available. Where data were available, 3% of food budget was attributed to entirely Victorian grown foods, including fresh fruit, vegetables, and poultry. A considerable proportion of Australian grown foods are purchased by this hospital, but it is largely unknown whether these are local, from the state of Victoria, or not. Tracing and sharing of food origin data, a clear definition for “local” food, and an understanding of Victorian food growing industries are needed to progress the “local food to hospital” agenda.

Dietary Patterns at the Individual Level through a Nutritional and Environmental Approach: The Case Study of a School Canteen

The public catering sector has important responsibilities in seeking a change toward more sustainable choices for many aspects related to the environmental impacts of their services. The environmental impact of production processes can be studied through life cycle assessment (LCA), which allows a greater awareness of choices and has rarely been applied to catering. In this work, we studied the impacts of two dishes (braised meat and cauliflower meatballs) in a school canteen, their impacts were studied using the daily energy requirement (expressed in kcal) as a functional unit. Global warming potential (GWP) and nonrenewable energy (NRE) were calculated starting from the supply of raw materials up to distribution. Electricity and the act of cooking the meatballs accounted for more than 60% of the measured impact in terms of GWP, whereas, less markedly, they dominated in terms of nonrenewable energy used. In the case of braised meat, the total impact was, however, attributable to the life cycle of the meat (between 60% and 76%) and the consumption of electricity (between 19% and 27%), whereas for all other factors, the contribution was never particularly high. Additionally, a discussion on the correct functional unit to be used proposed the environmental impact of different recipes as an additional criterion for nutritionists during the composition of the menu. An integrated system appears important for changing policies and behaviors and the application of LCA can be a tool capable of contributing to the construction of a holistic instrument of sustainability.

Climate Change Knowledge and Awareness of Nutrition Professionals: A Case Study from Turkey

Nutrition professionals (nutritionists and dietitians) assess nutritional and food-related health problems. They also identify appropriate interventions and support people in making dietary and lifestyle changes. The current climate change emergency constitutes a global threat to health, and the nutrition professionals can promote some diet-related alterations that encourage practical mitigation actions against it. This study assessed the knowledge and awareness levels of Turkish nutrition professionals about climate change by using a multiple-choice online quantitative survey conducted in 2021. It uses a sample of 1200 nutrition professionals who graduated from Turkish Universities. The findings showed that the participants’ climate change knowledge and awareness levels were correlated and significantly affected each other when it comes to understanding, responding, effects and awareness (p < 0.05). However, the links with knowledge about sustainable diet and scientific collaboration were statistically insignificant (p > 0.05). Educational and practice-based opportunities for linking climate change and diet-related advice are suggested for Turkish nutrition professionals.

[Quality and safety in clinical nutrition]

Clinical nutrition and food provision in a hospital environment must be regulated by quality management programs that ensure maximum clinical benefit and maximum patient safety. This article gives an overview of quality management in clinical nutrition and hospital feeding. Likewise, keys and critical points to be taken into account in all the processes and threads that are carried out during specialized nutritional support and alimentation of patients are analyzed.

Dietitians Australia position statement on healthy and sustainable diets

It is the position of Dietitians Australia that to promote human and planetary health, a food system transformation is needed that enables the population to adopt healthy and sustainable diet-related practices. A healthy and sustainable diet must (i) be nutritionally adequate, healthy and safe, (ii) have low environmental impact and be protective of natural resources and biodiversity, (iii) be culturally acceptable and (iv) be accessible, economically fair and affordable. Dietitians Australia acknowledges that it is critical to prioritise Indigenous knowledges in consultation, policy-making and implementation processes to achieve these recommendations. In facilitating the uptake of healthy and sustainable diets, dietitians are contributing to the transformation of our current food system that is urgently required to nourish present and future generations within planetary boundaries. In developing this position statement, opportunities for future research have been identified including those to advance the professions' capacity to improve environmental sustainability outcomes across all areas of practice. To achieve a population-level shift towards this diet, Dietitians Australia recommends: (i) the development of a National Food and Nutrition Strategy which honours Indigenous knowledges on food systems, (ii) the integration of sustainability principles in Australia's dietary guidelines, (iii) the reorientation of our food environment to prioritise access to healthy and sustainable foods, and (iv) investment in capacity building activities to equip the current and future nutrition and dietetics workforce.

Práticas ambientalmente sustentáveis em unidades de alimentação e nutrição hospitalares

Resumo Este estudo analisou as ações realizadas por Unidades de Alimentação e Nutrição - UAN hospitalares para a promoção da sustentabilidade ambiental. Participaram do estudo quatro das seis UANs de hospitais do município de Governador Valadares-MG. A coleta de dados foi realizada utilizando questionário online composto por 73 questões estruturadas sobre práticas de sustentabilidade ambiental na UAN. As ações estruturais menos prevalentes nos estabelecimentos foram as relacionadas a energia e iluminação (25%), e ventilação (38%). Aproximadamente, 93% das ações durante o planejamento de cardápio eram realizadas pelos estabelecimentos, porém 25% dos estabelecimentos não possuíam fichas técnicas de preparação. Apenas 35% das ações eram realizadas pelas unidades durante a aquisição e o armazenamento de insumos, sendo que nenhuma utilizava alimentos da agricultura familiar ou alimentos orgânicos. Durante o preparo, a distribuição e o consumo das refeições, 75,0% das ações realizadas se relacionaram ao aproveitamento integral dos alimentos. O controle de temperatura durante a distribuição de refeições foi a ação menos prevalente (50%). As unidades realizavam, em média, 93,8% das ações relacionadas aos procedimentos de higienização. Em relação a geração, coleta, armazenamento e destinação de resíduos, em média, 50% das ações eram adotadas nas UANs. Conclui-se que as UANs hospitalares de Governador Valadares-MG adotam medidas para a promoção da sustentabilidade ambiental, porém estas devem ser intensificadas, especialmente as relacionadas a capacitação da equipe, estrutura física, aquisição e recepção de insumos, e gestão de resíduos.

Effectiveness of strategies to decrease animal sourced protein and/or increase plant sourced protein in foodservice settings: a systematic literature review

BACKGROUND

Effective population-based strategies are required to move towards healthy sustainable diets which replace a proportion of animal- with plant-based protein. Foodservice can support this using a variety of strategies across the food supply chain.

OBJECTIVE

This systematic review aimed to evaluate the effectiveness of strategies to decrease animal protein and/or increase plant protein in foodservice settings on uptake, satisfaction, financial, environmental, and dietary intake outcomes.

METHODS

Seven databases were searched in November 2020 with no restriction on study dates to identify peer-reviewed study designs conducted in commercial and institutional foodservices using any strategy to decrease beef, lamb, pork, poultry, eggs, fish or seafood and/or increase legumes/pulses, legume/pulse-based meat substitutes or nuts and reported this review's primary outcome, uptake by consumers either quantitatively or qualitatively. Secondary outcomes were satisfaction and financial, environmental, and dietary intake outcomes. Titles/abstracts then full texts were screened independently by two authors. The Mixed Methods Appraisal Tool was used for quality appraisal. Results were described using a narrative synthesis by strategy type. The protocol is registered with PROSPERO (CRD42021235015).

RESULTS

From 20,002 records identified, 38 studies met eligibility criteria, of which 16% were high quality. Strategies included forced restriction (n=4), menu re-design (n=6), recipe re-design (n=6), service re-design (n=4), menu labelling (n=7), prompt at point of sale (n=7) and multi-pronged strategies (n=4). Menu labelling, prompting at the point of sale and re-designing menus, recipes, and service increased uptake of target foods in most studies with the largest consistent changes in menu re-design. Few studies explored secondary outcomes. Recipe re-design, prompt at the point of sale and menu labelling strategies that measured satisfaction found a positive or neutral effect.

CONCLUSIONS

The most promising strategies are likely in menu re-design, followed by menu labelling and service re-design. Satisfaction appears to not be negatively impacted by recipe re-design, prompting at the point of sale and menu labelling. More studies are needed to evaluate financial, environmental, and dietary outcomes.

The Drivers of Environmentally Sustainable Hospital Foodservices

Background: Hospital foodservices have the potential to positively contribute to the local food system and planetary healthcare. Understanding the factors contributing to the success of “exemplar hospitals” with environmentally sustainable foodservices gives an opportunity to reimagine foodservices and guide strategic planning. The aim of this study was to identify the drivers of sustainable hospital foodservices.

Methods: For this qualitative multiple case study, purposive sampling was used to identify exemplar hospitals internationally. Semi-structured interviews were conducted with staff with extensive knowledge of their foodservices to explore the drivers of sustainable practices. Relevant documents provided background on the case. These documents and interview data were analyzed using the framework and thematic analysis.

Findings: There were 21 participants from 14 hospitals recruited across nine countries. Sustainable foodservice practices included local and organic food procurement, gardens onsite, vegetarian menus, re-serving unopened portion-controlled items, traditional foods, and food waste composting. Four themes were identified: initiating drivers, supporting enablers, challenges, and influence. Initiating drivers that “sparked” sustainable practices included the values of individuals or the hospital (e.g., community, environmental, or religious values), logical solutions to a problem, or government requirements. Enablers that facilitated success included motivated individuals, dedicated personnel, supportive leadership, internal protocols, and perceived benefits. External enablers included being part of member organizations, government requirements, and learning from other hospitals. Exemplar hospitals had broader influence, including educating the hospital community, supporting other hospitals, and influencing government policies/targets. Common challenges were staff resistance and inadequate policy directive.

Interpretation: These findings examine the successful international cases of sustainable hospital foodservices to provide a global overview to assist with strategic planning both within hospitals and within governing bodies.