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Article

Determining Patient Satisfaction, Nutrition, and Environmental Impacts of Inpatient Food at a Tertiary Care Hospital in Canada: A Prospective Cohort Study

by
Annie Lalande
1,
Stephanie Alexis
2,
Penelope M. A. Brasher
3,
Neha Gadhari
4,
Jiaying Zhao
1,5 and
Andrea J. MacNeill
5,6,*
1
Institute for Resources, Environment and Sustainability, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
2
Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
3
Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC V5Z 1M9, Canada
4
Vancouver Coastal Health, Vancouver, BC V5Z 1M9, Canada
5
Department of Psychology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
6
Department of Surgery, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
*
Author to whom correspondence should be addressed.
Dietetics 2025, 4(3), 29; https://doi.org/10.3390/dietetics4030029
Submission received: 2 April 2025 / Revised: 26 April 2025 / Accepted: 30 June 2025 / Published: 10 July 2025
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Abstract

While hospital meals are designed to meet the nutritional requirements associated with illness or surgery, competing priorities often take precedence over food quality, contributing to poor patient satisfaction, in-hospital malnutrition, and high food waste. The environmental impacts of hospital food services are a less well-characterized dimension of this complex problem. A prospective cohort study of patients admitted for select abdominal surgeries between June and October 2021 was conducted at a tertiary care hospital in Canada. Greenhouse gas emissions and land-use impacts associated with all food items served were estimated, and patient food waste was weighed for each meal. Patients’ experience of hospital food was measured at discharge. Nutrition was assessed by comparing measured oral intake to minimum caloric and protein requirements. On average, food served in hospital resulted in 3.75 kg CO2e/patient/day and 6.44 m2/patient/day. Average food waste was 0.88–1.39 kg/patient/day (37.5–58.9% of food served). Patients met their caloric and protein requirements on 9.8% and 14.8% of days in hospital, respectively. For patient satisfaction, 75% of overall scores were lower than the industry benchmark, and food quality scores were inversely correlated with quantities of food wasted. Redesigning inpatient food offerings to feature high-quality, low-emissions meals could lessen their environmental impacts while improving patient nutritional status and experience.

Graphical Abstract

1. Introduction

Food is one of the most powerful levers to advance human health and environmental sustainability [1]. Current modes of food production and provision, now largely globalized and industrialized, generate 26–34% of global greenhouse gas (GHG) emissions, use 50% of habitable land, consume 70% of the world’s freshwater supply, and are major drivers of land-use change, eutrophication, and biodiversity loss [1,2,3]. The resulting climate and ecological crises are adversely affecting human health [4]. Over the last century, global dietary patterns have increasingly favored environmentally deleterious foods such as animal products and ultra-processed foods [5]. These shifts now represent a major risk factor for death [5,6] and non-communicable diseases, while driving environmental degradation [1,6].
Healthcare accounts for 4.6% of global GHG emissions, and food-related GHG emissions are estimated to contribute 10% to the healthcare footprint [4,7]. GHG emissions-intensive diets are commonplace in healthcare facilities [8], as hospital menus often feature pre-prepared, ultra-processed items and animal-sourced products to reduce cost, improve service efficiency and cater to the perceived preferences of patients [9,10,11]. While in-hospital meals are designed to meet the heightened nutritional requirements associated with illness or surgery [12], competing priorities often take precedence over food quality [13]. This contributes to poor patient satisfaction with hospital food, which has been associated with in-hospital malnutrition and increased healthcare expenditures [14,15,16]. Furthermore, poor food quality contributes to high rates of food waste in hospitals, with estimates ranging from 20% to 50% of food served [17,18].
Hospital food thus presents an opportunity to improve quality of care [12] while decarbonizing the health sector. Though the relationships between patient experience, nutrition, and food waste are well-documented [17,18], the environmental impacts of hospital food services are less well-characterized. The current study is a comprehensive assessment of the environmental impacts of food, patient satisfaction, and nutrition at a tertiary care hospital in Canada. The objectives of this study were to estimate GHG emissions and land-use impacts of food served, quantity of food wasted, nutritional adequacy of patient intake, and patient satisfaction.

2. Materials and Methods

We conducted a prospective cohort study to evaluate the current state of food production GHG emissions, food waste, patient satisfaction, and nutritional intake in a sample of surgical inpatients. The study was carried out at a 700-bed tertiary care centre in Vancouver, Canada, where meals are prepared in-house. Eligible patients were consecutively approached for enrolment before surgery and followed for the duration of their stay. The University of British Columbia (UBC) Clinical Research Ethics Board approved the study protocol (REB #H20-02993), and all participants provided written informed consent.
Patients aged 18–90 with an American Society of Anesthesiologists Physical Status (ASA-PS [19]) ≤ 3 admitted to the General Surgery service between June and September 2021 for scheduled abdominal procedures within the following list were included: hepatectomy, pancreatectomy, biliary resection, gastrectomy, small bowel resection, colectomy, proctectomy, pelvic exenteration, splenectomy, resection of retroperitoneal sarcoma, abdominal wall reconstruction, multivisceral resection, and cytoreductive surgery with heated intraperitoneal chemotherapy. These patients were selected as they are at moderate to high risk of malnutrition given their surgical intervention and expected postoperative physiologic changes [20]. Given the study questionnaire burden and the need for daily interactions with the research team, patients who were not comfortable with conversational English were excluded from the study.
The study was designed as a comparison group for a planned future study of a novel menu, with patient satisfaction as the primary outcome. We conducted a power analysis assuming alpha = 0.05 (2-tailed), power = 80%, and an effect size Cohen’s d = 0.3 for one-sample t-tests. The analysis showed a minimum sample of 90 patients was required. Since patients who were unable to tolerate oral intake for more than 30 days after surgery would be excluded from the analysis, we aimed to recruit an initial sample of 100 patients.

2.1. Environmental Impacts

GHG production emissions and land-use impacts of individual food items were estimated for all food served using the methodology described by Clark et al., in which item-specific emissions factors (EFs) and land-use factors (LFs) are used to estimate the environmental impacts of each foodstuff or ingredient, then aggregated into recipe-specific EFs and LFs [21]. Emissions and land use per portion served were based on standard individual portion weights. Recipes and portion sizes were obtained from the hospital dietary software system (Hospitality Suite by Computrition Inc., Canada). EFs and LFs were primarily obtained from the Cool Food Pledge database, which contains North American cradle-to-gate production factors for agricultural products from the work of Poore and Nemecek [2]. To address limitations in granularity of the Cool Food Pledge (CFP) database, the Blue Foods database was used instead to assign edible weight EFs and LFs to all seafood and fish products, considering the origin of the fish as wild or farmed [22]. All products requiring transformation from agricultural products and therefore not included in the CFP database, such as sauces, breads, and culinary ingredients (e.g., baking powder), were assigned EFs and LFs from the Clark Transformed Products database, which expanded on the CFP database [21]. Spices such as herbs, powders, salt, and pepper were excluded as they represented less than 1% of recipe weights. A cradle-to-gate approach was used. The environmental impacts of refrigeration, cooking, and cooking waste were excluded as their contributions were anticipated to be significantly smaller than those associated with food production [2,3].

2.2. Food Waste

Food waste was measured by weight-based plate waste assessment after each meal for up to two weeks for each patient [23]. All food contents on the collected meal tray were categorized according to leftover components and weighed using an OHAUS Valor 100 V11P3 scale. The weight of food served was obtained from the hospital dietary software system and was based on standardized portion sizes for each meal item. Plate waste weights were compared against weight served to determine patient intake. Waste percentages were calculated based on returned items, excluding trays or items that were missing or kept by the patient for later consumption. Due to a high rate of patient retention of snacks (62%), waste rates were not estimated for these items. Food wasted at the preparation and service stages was not captured.

2.3. Patient Experience

Patients’ experience of hospital food was measured at discharge using the Acute Care Hospital Foodservice Patient Satisfaction Questionnaire (ACHFPSQ) [24], a validated hospital food satisfaction questionnaire reporting aggregated measures for four dimensions of experience: food quality, service quality, staff or service issues, and physical environment. Patients were given the option of paper or electronic questionnaires and were encouraged to complete it on their own to limit the impact of social desirability bias. Additional multiple-choice questions were added to address some of the reported limitations of the ACHFPSQ, for instance, around reliance on outside food, and open-ended questions regarding the meals and service were included (Appendix A.1) [18,25].

2.4. Patient Nutrition

The nutritional value of food served was obtained from the hospital dietary software system. Minimum caloric and protein requirements were calculated for each patient, following the European Society of Parenteral and Enteral Nutrition 2021 Guidelines for clinical nutrition in surgery. Adjusted weights using the Hume formula were used for nutritional requirement calculations. A stress factor of 1–1.3, according to surgical type, was applied to the Harris-Benedict formula for caloric requirements calculations. Protein requirements were calculated using 1.3 g/kg/day [20]. The adequacy of patients’ nutritional intake was reported as the percentage of daily intake compared to the minimum daily caloric and protein requirements over the course of their stay, and the proportion of their stay in days in which nutritional intake was at least 90% of their minimum nutritional requirements.

2.5. Additional Variables

Patients’ demographic information (e.g., age, weight, height, admission diagnosis) was obtained from their electronic medical record. An admission survey was administered to obtain information on gender identification, cultural background, dietary habits, and climate change attitudes (Appendix A.1) [26]. Baseline nutritional status was assessed using the validated Nutrition Risk Screening 2 tool [27]. Short-term postoperative outcomes (length of stay, complication rates, readmission rates, reoperation rates) were collected from electronic medical records.

2.6. Data Capture and Statistical Analysis

Data were collected and manually entered into REDCap (Research Electronic Data Capture, version 15.0.29), with some direct electronic capture of patient surveys [28]. All data from patients who withdrew from the study were removed from the analysis. Descriptive summaries for food waste, GHG emissions and land use, patient experience, and nutritional intake and adequacy were determined. Continuous measures were summarized with means (SD), or medians (IQI) if the data were skewed. Categorical and ordinal data were summarized with frequency (proportion). To assess the association between patient characteristics (age, gender, level of concern about climate change, malnutrition risk, type of surgery, and length of stay) and their overall food experience, we fit separate normal linear regression models for each predictor. Departures from the assumptions of constant variance and normality were assessed via residuals. Normal linear regression was used to assess the association between patients’ overall satisfaction and perceptions of food quality and their average nutritional intake. A conceptual content analysis was carried out for open-ended questions to further characterize patient experience. Concepts, assigned at the statement level independently by two investigators (AL, NG), were grouped into overarching themes and coded for frequency. Discrepancies were discussed, and the senior investigator, AM, provided a final opinion when consensus was not achieved. All statistical analyses were conducted using R version 4.4.1 (R Core Team, Vienna, Austria, 2022). A value of p ≤ 0.05 was considered statistically significant.

3. Results

3.1. Demographics

A total of 100 patients were initially enrolled, and 91 completed the study. There was one early postoperative death, and eight patients withdrew. Response rates were high for both admission and discharge surveys (Figure 1). Patients were older, mostly White, mostly omnivorous, and 30.8% were at risk for malnutrition (Table 1). The median length of stay was 8 days, and 15.4% of patients experienced a serious adverse event (Clavien–Dindo grade 3a or higher) (Table 2).
Over the 91 patients’ hospital stays, a total of 2133 mealtimes were evaluated, with a median of 17 mealtimes per patient (Q1 = 11.5, Q3 = 29). Excluding meals where patients could not have food (nil per os, NPO), 518 breakfast, 504 lunch, and 500 dinner trays were assessed, encompassing a total of 15,574 assessed food items. For the meals evaluated, patients’ diets were primarily post-surgical transition (30.8%) or regular diets (20.2%), 23.7% were liquid diets, and 22.2% were NPO (see Appendix A.2 for therapeutic diet descriptions).

3.2. Environmental Impacts of Food Served

Total GHG emissions associated with food served were 2365 kg CO2e for the cohort; an average of 3.75 kg CO2e/patient/day (Q1 = 1.93, Q3 = 5.10), excluding complete NPO days. Average land use associated with food served was 6.44 m2/patient/day (Q1 = 2.75, Q3 = 8.27). Daily emissions and land use for patients receiving standard non-modified menus for various postoperative diets are shown in Table 3. For a regular diet, daily per-patient emissions ranged from 2.66 kg CO2e when the lowest-emission combination of lunch and dinner dishes was served (quiche and sole, respectively) to 7.41 kg CO2e when the highest-emission combination of dishes was served (grilled cheese sandwich and Salisbury steak) (Supplementary Materials Table S1). For a regular diet, most emissions were attributable to the protein component of the meals (63.8%) and beverages (17.5%); proteins accounted for 75.8% of daily land use. Patients were served a median of 154 g of meat per day (Q1 = 134, Q3 = 185) on a regular diet, compared to 80 g on a post-surgical transition diet (Q1 = 72, Q3 = 100), and 3 g (Q1 = 0, Q3 = 0) on a full fluid diet. Animal-sourced proteins were the default offering for all lunch and dinner meals on the solid diets examined.
For main dishes, standard servings of meat-based dishes had, on average, 4.5 times more emissions than vegetarian ones. Beef dishes had, on average, 14.7 times more emissions than vegan mains and 11.8 times more emissions than vegetarian mains (Figure 2). The highest-emissions beverages served were nutritional supplements, associated with 0.38 kg CO2e per portion, while per-portion emissions for milk were 0.27 kg CO2e and for juices were 0.098 kg CO2e.

3.3. Food Waste

Most patients progressed postoperatively from NPO or fluid diets to solid diets at the discretion of the clinical team. When not NPO, patients received an average (SD) of 2.27 kg (0.87) of food per day. By diet type, patients were served an average of 2.08 kg for clear fluids, 2.37 kg for full fluids (0.07), 2.56 kg for post-surgical transition diet (0.06), and 2.47 kg for regular diet (0.1). Measured food waste was 0.88 kg/patient/day (0.54), or 37.5% of food served. A total of 21.5% of food items were retained by patients (10.2%) or collected by food services (11.3%). If these were all wasted, food waste could be as high as 1.39 kg/patient/day (58.9% of food served). The lost nutritional value from wasted food for the entire study represented 58% of total calories served and 56% of protein calories served.
By weight, 49.3% of the total food waste was nutritional supplements, soups, juice, and coffee and tea (Figure 3). The proportion of food wasted was highest for condiments (77%) and beverages (62%) and lowest for desserts (37%). Individually packaged items, such as beverage cups and bottles and condiments, were frequently returned to the kitchen unopened, accounting for 42.3–67% of the food wasted for these items by weight (Appendix A.3).
Wasted food represented 44.7% of the GHG emissions of the food served; an average of 1.36 kg CO2e/patient/day (SD = 1.26). Food waste accounted for 2.29 m2 (SD = 2.85) of land use/patient/day, or 43.6% of the land use from food served. Mains and beverages were the largest sources of wasted GHG emissions and land use (Figure 3). Although proteins were consumed more fully than most other items on the tray (38.1% waste by weight, 31.8% waste by GHG emissions), they represented the largest contributor to the total emissions of food waste (37.2%) due to their higher emissions intensity.

3.4. Patient Outcomes

3.4.1. Patient Food Experience

Patient satisfaction scores were below industry benchmarks [24] for overall food satisfaction and food quality, while meal service quality, food service issues, and physical environment scores were at or above benchmarks (Figure 4). For 28.9% of patients, the meals worsened or greatly worsened their hospital experience. Food waste increased with decreasing satisfaction (Spearman’s rho = −0.26, 95% CI (−0.46, −0.04), p = 0.02) and decreasing perception of food quality (Pearson’s r = −0.32, 95% CI (−0.52, −0.13), p = 0.004). Age, gender, level of concern about climate change, malnutrition risk, type of surgery, and length of stay explained very little of the observed variation in patient satisfaction (Appendix A.4).
About half of the patients (n = 45) provided comments about the meals, and 87% (n = 47) of the comments were negative, pertaining to poor flavor and taste (n = 14), presentation (n = 11), ingredient quality (n = 7), and preparation (n = 5). Patients felt that food was important for recovery (n = 5), but the service was frustrating or reflected a lack of caring (n = 3). Some perceived the food to be unhealthy or not conducive to their recovery (n = 11). Half of the comments articulated issues around food quality, taste, and preparation, 10% specified that food options and portions were the reasons they were unable to finish their meals, and 33% identified medical issues such as nausea and lack of appetite as barriers to oral intake.

3.4.2. Patient Nutrition

On average, patients were NPO for 4.6 days (SD = 4.2, 31.9%), on liquid diets for 2.2 days (SD = 1.5, 24.1%), and on solid diets for 4.2 days (SD = 2.7, 53.1%). Average (SD) minimum caloric requirements were 1565 kcal/day (184) and average minimum protein requirements were 66.7 g/day (10.1). Patients’ average caloric intake from meals provided by the hospital was approximately half of these requirements (723.5 kcal/day, SD = 461 and 32.3 g/day, SD = 22.9, respectively). On days they were not NPO, patients consumed on average 47.4% of their caloric requirements (SD = 30.9) and 50.1% of their protein requirements (SD = 37.1). Over the course of their stay, patients met their requirements (within 10%) for calories 9.8% of the days, and for proteins 14.8% of the days, based on hospital food intake. Slightly more than half of patients reported relying on outside food for some or all of their meals (16.5%) or for occasional meals or snacks (36.7%).
Nutritional intake was lower in patients who underwent open compared to minimally invasive surgery (calories 46.1% vs. 52.3%; difference = 6.2%, 95% CI (−0.2, 12.6), p = 0.054) and protein 48.6% vs. 55.9%; difference = 7.2%, 95% CI (−0.6,15.11), p = 0.062). Intake was higher for patients on solid compared to liquid diets (calories 53.5% vs. 42.4%, p < 0.001 and protein 59.3% vs. 39.1%, p < 0.001). Very little of the observed variation in percent total caloric intake and percent protein caloric intake was explained by patient factors (Appendix A.5 and Appendix A.6).

4. Discussion

This study provides a comprehensive assessment of GHG emissions and land use associated with hospital food served and wasted, in relation to patient satisfaction and nutritional intake. We identified proteins as a major contributor to climate and land-use impacts, quantified high rates of food waste, and reported poor patient satisfaction which correlated with lower nutritional intake. These findings highlight the opportunity hospital food presents to mitigate healthcare environmental impacts while improving patient experience.
The inpatient menu was found to be emissions- and land-use-intensive due to the preponderance of animal-based protein, dairy, and nutritional supplements. The protein components of the main dishes were the primary drivers of emissions (63.8%) and land use (75.8%). Our average emissions intensity of 4.82 kg CO2e/day for a regular diet is comparable to that reported in a study of a hospital menu in Spain, where daily emissions for a regular diet were 5.08 kg CO2e [29]. Our results are also comparable to the average GHG emissions of 6.32 kg CO2e/day for an omnivore diet in Canada [30], calculated using EFs based on Canadian agricultural practices but using a farm-to-fork approach.
High volumes of food waste represent avoidable GHG emissions for healthcare facilities. In this study, 44.7% of food-related emissions were not consumed, which is comparable in scale to the findings of a single-day audit of food waste in Iran [31]. Differences in land-use impacts are most likely due to the higher frequency of fluid diets in our surgical patient population compared to the general patient population assessed in that study. Beverages were the most wasted foodstuff in this study, with milk and nutritional supplements being two of the highest-emission and most wasted items. Efforts to reduce food-related emissions and waste should address these high-impact items. In particular, future studies could target individually packaged non-perishable food items through reduced service and potential safe reuse. While not included in this work, food waste also generates GHG emissions from decomposition. Uneaten food in this hospital was primarily composted, which is preferable to disposal in landfill, but avoidance remains the preferred strategy for GHG emissions mitigation.
Our estimate of 0.88–1.39 kg of food waste per patient per day (37.5–58.9% of food served) is consistent with the high levels of reported food waste in other hospitals [17,18]. Our results are an underestimate, as they include only tray waste, excluding waste from upstream processes which reportedly account for at least 65% of total waste from food services operations [32]. Numerous initiatives have targeted food waste in hospitals, and achieved waste rates as low as 5–15% of food served [17,18]. These initiatives provide an opportunity to avoid lost nutritional value and improve health, wellbeing, and patient satisfaction.
The phenomenon of iatrogenic malnutrition and its impacts on recovery from illness have been well described [14,15]. While poor intake during acute illness is multifactorial, food quality has been identified as an important driver [16]. In this study, where 75% of patient satisfaction scores were below industry standards and nutritional intake from the hospital-provided food was severely and consistently inadequate, we demonstrate an inverse correlation between overall perception of food quality and food wasted during hospital admission. This measure does not capture the relationship between individual meal enjoyment and the quantity of food waste, which are likely to be more strongly correlated, but it does suggest that even if patients appreciated some meals, overall dissatisfaction remained an important contributor to poor intake.

4.1. Implications and Future Directions

Despite the perception that patients typically prefer meat-based dishes and the prevalence of meat in this study, patient satisfaction with food was poor. A recent survey in the UK suggested that most hospitalized patients do not feel strongly about access to red or processed meat in the hospital, and would be open to eating other dishes, including lower-emission animal-based proteins such as poultry or fish, or plant-based protein, provided they were appealing [9]. Thus, there may be an opportunity to improve patient satisfaction and mitigate hospital food-related environmental impacts by introducing nutritionally-adequate, plant-forward menus, as evidenced by the successful transition to default plant-based dishes in the 11 New York City Health and Hospitals facilities, as well as other institutions [11,33,34,35]. This could also serve to enhance cultural diversity and safety, as plant-forward diets are prevalent in many non-Western traditions. Given the relationship between patient food satisfaction and nutritional intake, a culinary focus on meal attributes such as taste or presentation will likely be central to achieving positive patient reception of plant-based dishes which may be unfamiliar or less enticing to some patient populations. In addition, ensuring the nutritional adequacy of more plant-rich diets will be a critical aspect of any program evaluation, as the lack of data currently contributes to the limited adoption of such diets in acute care settings despite well-established safety and benefits in community-dwelling populations [11,36,37].

4.2. Limitations

This study was carried out in a general surgical patient population, where a transition from liquid to solid diets is common; hence the type of food served, and the proportion of food wasted may not be generalizable to other patient populations. For a patient population consuming predominantly regular diets, the environmental impacts of hospital food would be expected to be higher than those reported here, irrespective of waste rates. Accurate waste rates were also limited by occasional missing trays and the patient tendency to retain items for possible later consumption. In examining nutritional intake, this study did not account for externally sourced food; thus, we may have underestimated patients’ total nutritional intake, as well as the total environmental impacts of all the food they consumed. We also did not assess changes in nutritional status during patients’ hospital stays. Finally, GHG emissions, land use, and waste from food preparation were excluded from this study but should be considered in the design of environmentally sustainable hospital food systems.

5. Conclusions

This study found that current hospital food services practices include emission- and land-intensive menus and result in substantial food waste, nutritional deficits, and low patient satisfaction. Redesigning inpatient menus to feature high-quality, low-emissions meals could lessen their environmental impacts while improving patient nutritional status, clinical outcomes, and experience. Several studies have reported favorable patient experience with plant-forward menus, but granular nutritional and food waste data are lacking, suggesting important directions for future studies.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/dietetics4030029/s1, Table S1: GHG Emission Factors and Land-Use Factors of Standard Portions of Meal Items Offered on the Standard Menu for the (A) Clear Fluid Diet, (B) Full Fluid Diet, (C) Post-Surgical Transition Diet, and (D) Regular Diet.

Author Contributions

A.L. designed the study with support from S.A., under the supervision of A.J.M. and J.Z. A.L. carried out the literature review. A.L., S.A. and N.G. performed the data collection. A.L. directly accessed and verified the underlying data reported in the manuscript. P.M.A.B. helped design the statistical analysis strategy, which A.L. performed under the guidance of P.M.A.B., J.Z. and A.J.M. A.L. was responsible for writing the manuscript, and all authors reviewed the manuscript. A.J.M. and J.Z. provided conceptual direction for the study. All authors have read and agreed to the published version of the manuscript.

Funding

Operational funding for this study was received from the Vancouver Coastal Health Research Institute (F19-05807). The funders were not involved in the research process, manuscript writing, or the decision to submit for publication.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Clinical Institutional Review Board of the University of British Columbia (#H20-02993, approval 22 June 2021).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The dataset is available on request from the authors.

Conflicts of Interest

The authors declare no conflict of interest, though do make note of some funding sources as follows. AL discloses salary support through a graduate scholarship grant from the Canadian Institute of Health Research, and support to attend meetings from a charitable organization, Nourish Leadership. AM discloses operational support for the project from the Vancouver Coastal Health Research Institute and the Vancouver General Hospital/University of British Columbia Hospital Foundation and Boehringer-Ingelheim philanthropic fund. AM has received grants from Environment and Climate Change Canada, the University of British Columbia, the Canadian Medical Association, Mitacs, and BC Renal, and receives royalties from UpToDate. AM has received honoraria for presentations at Dalhousie University and has obtained travel support for meetings from the National University of Singapore. AM holds leadership positions within CASCADES Canada, Vancouver Coastal Health, and the Lancet Commission on Sustainable Healthcare. SA, PB, NG, and JZ do not have any conflicts of interests to disclose. The funders had no role in the design of the study; in the collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Abbreviations

The following abbreviations are used in this manuscript:
ACHFPSQAcute Care Hospital Foodservice Patient Satisfaction Questionnaire
ASA-PSAmerican Society of Anesthesiologists Physical Status
CFPCool Food Pledge
EFEmission factor
LFLand-use factor
GHGGreenhouse gases
NPONil per os
UBCUniversity of British Columbia

Appendix A

Appendix A.1. Admission and Discharge Surveys

Admission survey
(1)
What gender do you identify with?
○
Male
○
Female
○
Transgender
○
Non-binary
○
Two-spirit
○
Other
○
Prefer not to disclose
(2)
What is your biological sex?
○
Male
○
Female
○
Prefer not to disclose
(3)
What is the ethnic background you identify with? (select all that apply)
○
Indigenous peoples of Canada
○
Indigenous (outside of Canada)
○
Chinese (including Mainland China, Hong Kong, Macau, and Taiwan)
○
Black (African)
○
Black (Caribbean)
○
Black (other)
○
Arab
○
Japanese
○
Korean
○
Filipino
○
Central or South America
○
South Asian (e.g., Indian, Pakistani, Sri Lanken, etc.)
○
Southeast Asian (e.g., Cambodian, Indonesian, Laotian, Vietnamese, etc.)
○
West Asian (e.g., Afghan, Iranian, Syranian, etc.)
○
White
○
Other
○
Prefer not to disclose
(4)
What is your current religion, if any?
○
Anglican
○
Baptist
○
Buddhist
○
Catholic
○
Christian
○
Christian Orthodox
○
Christian (Other)
○
Hindu
○
Jewish
○
Lutheran
○
Muslim
○
Pentecostal
○
Presbyterian
○
Sikh
○
Traditional (Aboriginal) Spirituality
○
United Church
○
Other religions
○
No religious affiliation
○
Prefer not to disclose
(5)
What is the highest level of education you’ve completed?
○
Secondary education or lower
○
Certificate or college degree
○
Bachelor’s degree
○
Master’s degree
○
Doctoral degree (Ph.D.)
○
Professional degree (M.D., J.D., O.D., D.O., D.M.D., D.D.S.)
(6)
What is your net annual income?
○
CAD 0 to CAD 19,999
○
CAD 20,000 to CAD 39,999
○
CAD 30,000 to CAD 49,999
○
CAD 50,000 to CAD 69,999
○
CAD 70,000 to CAD 99,999
○
CAD 100,000 to CAD 149,999
○
CAD 150,000 to CAD 199,999
○
CAD 200,000 and up
(7)
Where you live, who usually cooks the meals?
○
I cook for myself only
○
I cook for myself and the people I live with
○
I cook for myself part of the time, and someone else cooks for me part of the time
○
Someone mostly cooks for me
○
I order in or eat out most of the time
(8)
How would you describe your diet?
○
Vegan (I do not eat any animal products)
○
Vegetarian (I eat dairy and/or eggs but no other animal products)
○
Pescatarian (I eat fish but no other types of meat)
○
Flexitarian (I mostly eat vegetarian, but I occasionally eat meat)
○
Omnivore (I eat food from all groups)
○
Carnivore (I consume mostly or exclusively meat)
○
Other
(9)
Do you currently suffer from any medical conditions or medication side effects, or have you had any surgeries that affect your ability to eat or digest food, or have changed your appetite significantly for a prolonged period of time (> 1 month)? If yes, select all that apply.
○
No
○
Yes, difficulty chewing
○
Yes, inability/difficulty swallowing
○
Yes, difficulty absorbing food (loose bowel movements/chronic diarrhea)
○
Yes, difficulty eating large meals
○
Yes, needing to alter diet to avoid large quantities of fiber
○
Yes, having poor appetite
○
Yes, having chronic nausea
○
Yes, being unable to taste/smell like I used to
(10)
How important is the issue of climate change to you personally?
○
Extremely important
○
Very important
○
Somewhat important
○
Not too important
○
Not at all important
(11)
How worried are you about climate change?
○
Very worried
○
Somewhat worried
○
Not very worried
○
Not at all worried
(12)
How much do you think climate change will harm you personally?
○
A great deal
○
A moderate amount
○
Only a little
○
Not at all
○
Don’t know
(13)
How much do you think climate change will harm future generations of people?
○
A great deal
○
A moderate amount
○
Only a little
○
Not at all
○
Don’t know
Discharge survey
For the following questions, think of all the food that you have had in the hospital during your stay. If the question does not apply, please leave the answer blank. Rated from 5-Always to 1-Never.
(1)
The crockery and cutlery are chipped and/or stained
(2)
The staff who deliver my meals are neat and clean
(3)
The hospital smells stop me from enjoying my meals
(4)
I am able to choose a healthy meal in hospital
(5)
I am disturbed by the noise of finished meal trays being removed
(6)
The cold drinks are just the right temperature
(7)
I like the way the vegetables are cooked
(8)
The meals taste nice
(9)
The hot drinks are just the right temperature
(10)
The staff who take away my finished meal tray are friendly and polite
(11)
I like to be able to choose different-sized meals
(12)
The menu has enough variety for me to choose meals that I want to eat
(13)
The cold foods are the right temperature
(14)
The staff who deliver my meals are helpful
(15)
The meals have excellent and distinct flavors
(16)
The hot foods are just the right temperature
(17)
The meat is tough and dry
(18)
I receive enough food
(19)
I still feel hungry after my meals
(20)
I feel hungry in between my meals
(21)
As compared to your normal food intake, how would you rate your food intake for the majority of the hospital stay (this time)?
○
Unchanged
○
More than usual
○
Less than usual
(22)
Thinking of all your meals during your stay, how much of it did you eat on average?
○
None
○
A few bites of the meal
○
A quarter of the meal
○
Half of the meal
○
Three quarters of the meal
○
All of the meal
(23)
When you did not eat all your meals, what was the main reason you were not able to eat all of it?
(24)
How often do you eat food from outside [for instance, brought into the hospital (friends, family, caretaker, etc.), bought at the cafeteria, hospital cafe or neighboring shops/restaurants, or delivered to the hospital]?
○
Every meal
○
Most meals
○
Some meals
○
A few meals
○
Only for snacks, but not for meals
○
Never
(25)
Overall, how would you rate your satisfaction with the food service?
○
Very good
○
Good
○
Okay
○
Poor
○
Very poor
(26)
During your stay, have you been asked for your dietary preferences?
○
Yes
○
No
(27)
During your stay, have you been asked for your meal preferences?
○
Yes
○
No
(28)
If you asked for a specific meal, did you get what you asked for?
○
All the time
○
Most of the time
○
Some of the time
○
Rarely
○
Never
○
Not applicable
(29)
Were the meals that were served to you the type of food you would usually eat?
○
Yes
○
No
(30)
Please select the option that best describes your experience in the hospital:
○
The food the hospital provided during my stay…
○
Greatly improved my experience
○
Improved my experience
○
Did not impact my experience
○
Worsened my experience
○
Greatly worsened my experience
(31)
Do you have any further comments on the meals during your stay?
(32)
If you could have anything you wanted to eat during your stay, what would you like to eat? List up to five meal options.
How important would each of these aspects be in making the hospital food as good as possible? Rated from 5-Very important to 1-Not important.
(33)
Taste
(34)
Quality
(35)
Presentation
(36)
Temperature
(37)
Environmental impact
(38)
Social impact (ethically made, fair wages, worker conditions and rights, etc.)
(39)
Amount of packaging
(40)
GMO-free
(41)
Organic
(42)
Locally sourced
(43)
In season
(44)
Familiar to me
(45)
Comforting

Appendix A.2. Description of Therapeutic Diets Used in the Postoperative Setting and Frequency of Use in Study Patients for the 2133 Individual Mealtimes Included in This Study

Diet NameDiet DescriptionAverage Daily Calories (kCal)Average Daily Protein (g)Number of Trays Served to the Study Patients (%)
Nil per osNo food allowed00474 (22.2%)
Clear fluidsOnly transparent liquids such as broth, juice, and jello5953.7256 (12.0%)
Full fluidsThickened liquids or semi-liquids allowed, such as nutritional supplements, yogurt, oatmeal106139.6250 (11.7%)
Post-surgical transition dietFiber-restricted, with smaller portions and evening snacks162867.3658 (30.8%)
Post-gastric-surgery dietLimited in sugar to avoid dumping syndrome171285.813 (0.6%)
Ileostomy dietHigh soluble fiber and salt for new and problematic ileostomies222296.737 (1.7%)
Regular dietUnrestricted diet, meets Canada Dietary Guidelines 2007183485.2428 (20.2%)

Appendix A.3. Food Waste from Individually Packaged Beverages and Condiments by Item Category by Weight and from Unopened Containers

Weight of Food Waste (kg, % of Total Served)Number of Unopened Items Wasted (% of Served)Percentage of Total Food Waste from Unopened Items by Weight (%)
Dairy milk100.8 (67.1%)344 (28.4%)42.3%
Juice87.6 (61.9%)357 (29.1%)47%
Nutritional supplements44.6 (51.5%)88 (26.1%)50.7%
Milkers and creamers5.1 (75.3%)535 (50.4%)67%
Butters and margarine1.9 (78.8%)160 (44.2%)56.1%
Dressings0.6 (68.8%)13 (29.5%)43%
Spreads and jams3.3 (66.9%)116 (34.8%)52%
Sugars and sweeteners4.8 (79.3%)896 (52.3%)66%

Appendix A.4. Association of Patients’ Overall Satisfaction and Patient Demographics, Climate Concern, and Length of Stay (N = 79)

Variable β ^ 95 %   C I R2p
Age 0.01 (−0.01,0.03)0.020.18
Gender (n = 75) 0.050.14
  Male2.82 (2.42, 3.21)
  Female0.26 (−0.28, 0.78)
  Two-spirit2.18 (−0.13, 4.49)
Malnutrition 0.030.36
  Low risk2.91 (2.6, 3.22)
  At risk−0.08 (−0.81, 0.66)
  High risk0.51 (−0.23, 1.25)
Concern about climate change (n = 77) 0.0380.74
  Dismissive2.71 (1.83, 3.6)
  Doubtful0.04 (−1.17,1.25)
  Disengaged0.69 (−0.47, 1.84)
  Cautious0.29 (−0.87, 1.44)
  Concerned0.04 (−1.02, 1.1)
  Alarmed0.37 (−0.63, 1.37)
Type of surgery 0.110.039
  Abdominal surgery, no resection4 (1.72, 6.28)
  Abdominal wall reconstruction−0.5 (−3.05, 2.05)
  Hepatico–pancreatico–biliary−0.84 (−3.15, 1.47)
  Lower gastro-intestinal−1.29 (−3.62, 1.05)
  Multivisceral resection−2.2 (−4.69, 0.29)
  Solid organ resection−0.88 (−3.29, 1.54)
  Upper gastro-intestinal−1 (−3.63, 1.63)
Length of stay0.01 (−0.02, 0.04)0.0020.68

Appendix A.5. Association of Patients’ Average Percentage of Caloric Intake and Patients’ Nutrition Risk, Overall Satisfaction, and Food Quality Scores (N = 91)

Variable β ^ 95 %   C I R2p
Malnutrition 0.00580.78
  Low risk1.41 (−0.14, 2.95)
  At risk−0.97 (−4.66, 2.72)
  High risk−0.94 (−4.62,2.49)
Overall satisfaction0.05 (−1.26, 1.36)6.8 × 10−50.94
Food quality−0.73 (−2.95, 1.48)0.00570.51

Appendix A.6. Association of Patients’ Average Percentage of Protein Intake and Patients’ Nutrition Risk, Overall Satisfaction, and Food Quality Scores (N = 91)

Variable β ^ 95 % C I R2p
Malnutrition 0.020.42
  Low risk0.52 (0.46, 0.57)
  At risk−0.08 (−0.22, 0.05)
  High risk−0.04 (−0.17, 0.08)
Overall satisfaction0.03 (−0.01, 0.08)0.0270.16
Food quality0.06 (−0.01, 0.14)0.0370.09

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Dietetics 04 00029 g001
Figure 1. Patient flow from recruitment to study completion.
Figure 1. Patient flow from recruitment to study completion.
Dietetics 04 00029 g001
Dietetics 04 00029 g002
Figure 2. GHG emissions (A) and land use (B) per standard portion of main dishes based on protein source; jittered points represent each dish, while boxes represent quartiles.
Figure 2. GHG emissions (A) and land use (B) per standard portion of main dishes based on protein source; jittered points represent each dish, while boxes represent quartiles.
Dietetics 04 00029 g002
Dietetics 04 00029 g003aDietetics 04 00029 g003b
Figure 3. Average weight (A), GHG emissions (B), and land use (C) of food served, wasted, and percent wasted per item type per patient per day for beverages, mains, desserts, and condiments, in decreasing order by category. Average GHG emissions waste by category: beverages 0.68 kg CO2e/patient/day (50.5% of total wasted emissions), mains 0.54 kg CO2e/patient/day (39.9%), desserts 0.096 kg CO2e/patient/day (7.2%), and condiments 0.032 kg CO2e/patient/day (2.4%).
Figure 3. Average weight (A), GHG emissions (B), and land use (C) of food served, wasted, and percent wasted per item type per patient per day for beverages, mains, desserts, and condiments, in decreasing order by category. Average GHG emissions waste by category: beverages 0.68 kg CO2e/patient/day (50.5% of total wasted emissions), mains 0.54 kg CO2e/patient/day (39.9%), desserts 0.096 kg CO2e/patient/day (7.2%), and condiments 0.032 kg CO2e/patient/day (2.4%).
Dietetics 04 00029 g003aDietetics 04 00029 g003b
Dietetics 04 00029 g004
Figure 4. Patient satisfaction reported according to the Acute Care Hospital Foodservices Patient Satisfaction Questionnaire methodology, with the industry benchmark denoted by the dashed dark line.
Figure 4. Patient satisfaction reported according to the Acute Care Hospital Foodservices Patient Satisfaction Questionnaire methodology, with the industry benchmark denoted by the dashed dark line.
Dietetics 04 00029 g004
Table 1. Demographic characteristics of study participants.
Table 1. Demographic characteristics of study participants.
Characteristics
Age (n = 91)Mean = 62 (SD = 12.4)
Gender (n = 83)Men: 38 (45.7%)
Women: 44 (53%)
Ethnicity (n = 83)Did not disclose: 1 (1.2%)
White: 58 (69.9%)
Asian: 19 (22.9%)
Indigenous: 4 (4.8%)
Other or no answer: 2 (2.4%)
ASA-PS * (n = 91)1: 3 (3.3%)
2: 36 (39.6%)
3: 52 (57.1%)
CCI ** (n = 91)Median = 4 (Q1 = 3, Q3 = 6)
BMI *** (n = 91)Mean = 26.9 (SD = 5.9)
Malnutrition NRS-2, age-adjusted (n = 91)Low risk: 63 (69.2%)
At risk: 13 (14.3%)
High risk: 15 (16.5%)
Malignancy (n = 91)Confirmed: 61 (67%)
Suspected: 9 (9.9%)
Benign: 21 (23.1%)
Surgery (n = 91)Hepatopancreaticobiliary: 43 (47.3%)
Lower gastrointestinal: 24 (26.4%)
Solid organ resection: 8 (8.8%)
Multivisceral resection: 7 (7.7%)
Abdominal wall reconstruction: 5 (5.5%)
Upper gastrointestinal: 3 (3.3%)
Lysis of adhesions: 1 (1.1%)
Approach (n = 91)Open or converted: 65 (71.4%)
Laparoscopic or hand-assisted: 24 (26.4%)
Robotic: 2 (2.2%)
Diet (n = 83)Omnivore: 70 (84.3%)
Flexitarian: 9 (10.8%)
Vegetarian or vegan: 4 (4.8%)
SASSY **** (n = 83)Alarmed: 30 (36.1%)
Concerned: 25 (30.1%)
Cautious: 12 (14.5%)
Disengaged: 3 (3.6%)
Doubtful: 8 (9.6%)
Dismissive: 2 (2.4%)
Did not respond: 3 (3.6%)
* American Society of Anesthesiologists Physical Status; ** Charlson Comorbidity Index; *** Body Mass Index; **** Six Americas Super Short Survey on climate change [26].
Table 2. Short-term postoperative outcomes.
Table 2. Short-term postoperative outcomes.
Outcome
Median length of stay8 days (Q1 = 5.0, Q3 = 12.5)
Any complicationn = 30 (33.0%)
Highest Clavien–Dindo Grade for
complications		Grade 1: n = 2 (2.2%)
Grade 2: n = 14 (15.2%)
Grade 3a: n = 4 (4.4%)
Grade 3b: n = 5 (5.4%)
Grade 4a: n = 3 (3.3%)
Grade 4b: n = 1 (1.1%)
Grade 5: n = 1 (1.1%)
Readmission at 30 daysn = 16 (17.6%)
Table 3. GHG emissions and land use for perioperative therapeutic diets, in total and by diet component.
Table 3. GHG emissions and land use for perioperative therapeutic diets, in total and by diet component.
Clear Fluid DietFull Fluid DietPost-Surgical Transition DietRegular Diet
GHG emissions (kg CO2e)
Total0.8142.4013.7284.816
Components
  Beverages0.6651.4631.1010.832
  Soups0.0290.1830.2600.124
  Proteins001.6503.073
  Starch00.0820.1930.217
  Vegetables000.0460.123
  Fruit000.0930.057
  Desserts0.1000.5860.2490.243
  Condiments0.0200.0850.1380.148
Land use (m2)
Total0.8262.6746.45810.418
Components
  Beverages0.6461.4551.1310.877
  Soups0.0460.3350.4830.303
  Proteins003.8568.016
  Starch00.1960.3370.456
  Vegetables000.1190.384
  Fruit000.1020.067
  Desserts0.1040.5950.2740.300
  Condiments0.0290.0940.1560.175
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Lalande, A.; Alexis, S.; Brasher, P.M.A.; Gadhari, N.; Zhao, J.; MacNeill, A.J. Determining Patient Satisfaction, Nutrition, and Environmental Impacts of Inpatient Food at a Tertiary Care Hospital in Canada: A Prospective Cohort Study. Dietetics 2025, 4, 29. https://doi.org/10.3390/dietetics4030029

AMA Style

Lalande A, Alexis S, Brasher PMA, Gadhari N, Zhao J, MacNeill AJ. Determining Patient Satisfaction, Nutrition, and Environmental Impacts of Inpatient Food at a Tertiary Care Hospital in Canada: A Prospective Cohort Study. Dietetics. 2025; 4(3):29. https://doi.org/10.3390/dietetics4030029

Chicago/Turabian Style

Lalande, Annie, Stephanie Alexis, Penelope M. A. Brasher, Neha Gadhari, Jiaying Zhao, and Andrea J. MacNeill. 2025. "Determining Patient Satisfaction, Nutrition, and Environmental Impacts of Inpatient Food at a Tertiary Care Hospital in Canada: A Prospective Cohort Study" Dietetics 4, no. 3: 29. https://doi.org/10.3390/dietetics4030029

APA Style

Lalande, A., Alexis, S., Brasher, P. M. A., Gadhari, N., Zhao, J., & MacNeill, A. J. (2025). Determining Patient Satisfaction, Nutrition, and Environmental Impacts of Inpatient Food at a Tertiary Care Hospital in Canada: A Prospective Cohort Study. Dietetics, 4(3), 29. https://doi.org/10.3390/dietetics4030029

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