Environmental Sustainability of Hospital Foodservices across the Food Supply Chain: A Systematic Review (2020 May)

Citation: Carino S, Porter J, Malekpour S, Collins J. Environmental Sustainability of Hospital Foodservices across the Food Supply Chain: A Systematic Review. J Acad Nutr Diet. 2020 May;120(5):825-873. doi:10.1016/j.jand.2020.01.001. Epub 2020 Feb 21. PMID: 32093919. (note: there is a paywall to access the full study)

Relevant to: 

Dietitians-Nutritionists working clinical, administrative or food-service roles in hospitals, particularly for those working on policy development or menu redesign for sustainability. 


This systematic review of 80 studies across the globe examined: environmental and associated economic impacts of foodservice; outcomes of strategies that aim to advance environmental sustainability; and perspectives of stakeholder – across the hospital supply chain. 

Bottom line for nutrition practice: 

While not solely responsible for environmental sustainability initiatives, this evidence tells us that dietitians have a strong influence over hospital food services, and food in the hospital is a strong driver of environmental impacts. Therefore, Dietitians-Nutritionists should be at the table, collaborating with management to support this effort.  

There is a need to influence beliefs and values that support environmental sustainability broadly among hospital staff. Such cultural shifts support directors to influence more systemic policy shifts and strategies. Systems thinking is required. This means planning with the whole hospital food system in mind, to maximize benefits (e.g., co-benefits between decreased food waste, increased food and nutrient intake, recovery times, and decreased costs). It also is reliant on a multidisciplinary team who can integrate sustainability outcomes into daily decision making and data collection for evaluation. 

In order to encourage dietitians to participate effectively in a systemic way, education is critical – both in undergraduate studies and in the workplace. 


  • 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.  

Details of results: 

The results demonstrated that research in this this area has mostly concentrated on food waste and procurement (for the latter, specifically local food purchasing). The authors state that the results highlight specifics opportunities and barriers. Challenges to more sustainable procurement included logistical barriers, requirement for efficiency, budget constraints, menu modifications, lack of resources, funding, and knowledge. Further, while group purchasing organizations can be helpful for reducing prices through economies of scale, they can present barriers in sustainable procurement – in particular, local purchasing. The authors note, however, that local procurement, while contributing to local economic and social goals, is not necessarily more environmentally sustainable. The authors further acknowledge that hospitals must address a complex mix of patients’ nutritional needs, patient groups, funding constraints, as well as standards related to infection control, accreditation and legislation.  
Opportunities noted include an interest by hospital foodservices for environmentally sustainable practices and the potential for building relationships with the community through local procurement. The authors stress that ground-up, immediate action is needed in parallel with longer term system-wide solutions. They also recommend that non-governmental organisations, such as Health Care Without Harm and Practice Greenhealth offer evidence-based toolkits (step-by-step guides) to overcome barriers and leverage opportunities. The authors note that the lack of research across some levels of the hospital food chain illustrates a need to train health professionals in research.   

Food waste was the most commonly explored environmental impact in the studies reviewed. Food waste is a significant portion of hospital waste (20 to 30% on average, but as high as 74%).  Food waste (including packaging waste) has potential food safety trade-offs and is perceived to be a significant barrier by staff. Waste avoidance and reduction is the most preferred solution. Various food service models such as those offering patient choice and reduced time between ordering and eating (e.g., room service models, meal trolleys, etc.) can reduce food waste, as can other techniques, such as increasing the energy density of meals. Post consumption, most hospital food waste goes to the landfill, while diverting waste for animal feed or composting to enhance soils is rare. Food recovery strategies (e.g., to food banks) is challenged by food safety regulations. All forms of waste reduction and recovery present opportunities for dietitians to collaborate across sectors to innovate for sustainable waste solutions. For example, measuring and monitoring food waste was identified as an important way not only to reduce waste, but also to increase awareness with stakeholders. Finally, the results suggest that balancing food safety requirements with sustainability efforts can be a barrier. 

Of additional interest: 

The food waste hierarchy (from best to least desirable) is: reduction, feeding hungry people, feeding animals, industrial uses, composting, and landfill/ incineration. Food waste is the largest emitter of methane and has a global warming potential of 25 times more than carbon dioxide. Transporting food to landfill also has significant costs. Using food waste to feed animals, for conversion to energy, or as food for feeding animals or for composting to enhance soils can have some positive contribution to the environment (e.g., enhancing soil quality, creating compost for gardening).  

A circular economy can be beneficial to reduce waste through using natural resources and recycling them after their initial use. This needs to be carefully assessed due to the potential of some risks such as inhalation of bio aerosols and food poisoning.  

Editor’s comment:  

The suggested method of increasing the energy density of meals to decrease waste should also be carefully assessed, as some energy dense foods (e.g., ruminant meat) may be associated with higher environmental costs.  

Open access link to article: 

N/A – there is a pay wall to access the article (see citation above)

Conflict of interest/ Funding: 


External relevant links: 

Health Care without Harm: https://noharm.org/ 

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