sustainability
Article
Hospital Plate Waste Assessment after Modifications in Specific
Dishes of Flexible and Inflexible Food Ordering Systems
Lourdes Paiva 1 , Carla Hernández 1 , Diana Santos 1 , Roncesvalles Garayoa 1,2,3, *, Laura García 4 ,
Claudia Urdangarín 4 and Ana Isabel Vitas 3,5
Citation: Paiva, L.; Hernández, C.;
Santos, D.; Garayoa, R.; García, L.;
Urdangarín, C.; Vitas, A.I. Hospital
Plate Waste Assessment after
Modifications in Specific Dishes of
Flexible and Inflexible Food Ordering
Systems. Sustainability 2022, 14, 15616.
https://doi.org/10.3390/su142315616
Academic Editor: Ada Margarida
Correia Nunes Da Rocha
Received: 10 October 2022
Accepted: 22 November 2022
Published: 24 November 2022
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Sustainability 2022, 14, 15616. https://doi.org/10.3390/su142315616
1 Department of Nutrition, Food Science and Physiology, School of Pharmacy, University of Navarra,
Irunlarrea 1, 31008 Pamplona, Spain
2 Center for Nutrition Research, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain
3 IdisNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
4 Diets Area, University Clinic of Navarra, Irunlarrea 1, 31008 Pamplona, Spain
5 Department of Microbiology and Parasitology, School of Medicine, University of Navarra, Irunlarrea 1,
31008 Pamplona, Spain
* Correspondence: rgarayoa@unav.es; Tel.: +34-948425600
Abstract: Previous studies on hospital food waste have focused on raising awareness among patients
about this problem. The aim of the study was to quantify the food waste in a flexible and inflexible
ordering system from a hospital located in the north of Spain in order to implement specific modifica-
tions to reduce the waste. The avoidable waste of 15 dishes was determined in the flexible (choice
menu) and inflexible (basal diet) ordering system by weighing the avoidable waste from the same
dish and diet by conglomerate. Milk, chicken and lunch fish generated more than 25% of plate waste
and were classified as critical dishes, with the choice menu being the one that obtained the lowest
percentages of waste. The implemented modifications in the case of milk (reducing the serving size)
did not decrease the waste percentage. By contrast, the new chicken recipes and the increased fish
variety in the inflexible ordering system decreased the plate waste in both dishes from 35.7% to 7.2%
and from 29.5% to 12.8%, respectively. Identifying critical dishes, implementing actions to reduce the
food waste and monitoring the progress are essential measures to decrease plate waste in hospitals.
Keywords: plate waste; hospital; food service; milk waste; chicken waste; fish waste
1. Introduction
According to the United Nations, 17% of available food is wasted [1]. This translates
to the unnecessary loss of all resources used for the production of these foods, with
the aggravating circumstance that natural resources are deficient in many parts of the
world. It is estimated that two-thirds of the fresh water available on our planet is used
for crop irrigation and food wasted annually globally consumes 306 km3 of water in its
production [2]. On the other hand, food waste also contributes to climate change as the
food chain produces 34% of global greenhouse gases [3]. In addition, it is unethical that
while one part of the population throws away food, the other is in need of it [4]. In
2020, after the coronavirus disease pandemic (COVID-19), the number of undernourished
people was estimated to increase by 132 million to 820 million people (8.9% of the world’s
population) [5].
A European food waste study stated that 50% of the avoidable and unavoidable
food waste occurs at the consumption stage [6]. Most of the avoidable waste comes from
households (11%) and food services (5%), with associated costs of EUR 98 billion and EUR
20 billion, respectively [7]. At the hospital level, Carino et al. [8] found that food waste
represents around 20% to 30% of the overall hospital waste, although a range from 17%
to 74% was reported. Food waste in hospitals means a lower food intake by patients, that
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Sustainability 2022, 14, 15616 2 of 9

contributes partly to deterioration in the patients’ nutritional status as reported by van

Bokhorst et al. [9].
All of this opposes the 12th Sustainable Development Goal (SDG) [10]. This goal
attempts to ensure responsible production and consumption patterns in general, but target
12.3 focuses exclusively on food waste, seeking to reduce global food waste per capita by
a half at the production and consumer level by 2030 [1]. These facts have led researchers
across Europe to develop studies addressing hospital food waste and other issues as
part of a more sustainable food strategy [11]. One of the largest studies developed by
Health Care Without Harm Europe (HCWH) is the Model of Circular Economy of French
Hospitals (MECAHF) project [12]. After quantifying the waste, they implemented actions
to reduce waste by focusing on raising awareness among patients about this problem
through leaflets and posters. In re-evaluating the situation, they observed a 20% decrease
in the generated waste.
In this context, the main aim of this study was to quantify the food waste from a
hospital located in the north of Spain, in order to propose some measures to reduce it. Thus,
the avoidable waste of the dishes in the basal diet (inflexible ordering system) and in the
choice menu (flexible ordering system) was determined and compared in the first stage.
According to the quantified waste, some modifications were applied in plates classified as
“critical” in order to reduce food waste, and new quantifications were performed in the
second stage.

2. Materials and Methods

2.1. Case Study Description
The study was carried out in a private hospital located in the north of Spain, with
26 areas of specialization and an availability of 400 beds.
The catering food system offers 125 diet categories, according to the clinical and
pathological situation of patients. The study was performed in the two most extensive
ones among the standard adult diets: the basal diet and the choice menu (inflexible and
flexible ordering systems, respectively). These two diets are designed for patients who do
not need specific dietary changes and are prescribed according to the doctor’s opinion. The
unique difference between both diets is the possibility of choosing between 6 options for
each first course, main course, dessert and drink in the choice menu. The basal diet (with
no possibility of choice) is usually prescribed when it is necessary to monitor the patient
intake or depending on the time of admission.
A menu rotation is carried out every 4 weeks. All meals are cooked daily and served
in individual trays, which are transported in trolleys at scheduled times (breakfast at 8:30
a.m., lunch at 1:10 p.m., dinner at 7:45 p.m.). The study was carried out on the three main
meals (breakfast, lunch and dinner), including salted and unsalted preparations.
The case study was divided into 2 phases (Figure 1). The first one corresponds to
the plate waste analysis performed between 2018 and 2019 on 4641 plates from both diets
(basal and choice menu), before the dietary department implemented modifications on
dishes (Table 1). Phase 2 corresponds to the re-evaluation of plate waste on the identified
“critical plates” according to the determined waste (≥ 25% plate waste per person a day),
one year after the implementation of modifications (Figure 2), covering a total of 695 plates
from the basal diet.

2.2. Food Waste Quantification Method

Food waste of dishes from Table 1 was determined and referred to as plate waste (PW).
PW was measured by weighing food as this methodology has been reported to provide
more accurate and objective results, despite it requiring more resources and time [13].
According to Strotmann et al. [14], wastes were quantified on working days excluding
weekends, vacation periods and public holidays. During the plating of each main meal, a
colored tablecloth was placed on the trays from which the waste would be quantified. In
phase 2, trays from COVID-19 patients were excluded to avoid cross-contamination.
Sustainability
Sustainability 2022, 14,
2022,14,
Sustainability2022, xxFOR
FORPEER
14,15616 PEERREVIEW
REVIEW 33ofof99

Figure1.1.Flow
Figure Flowchart
chartof
ofthe
theperformed study.
performedstudy.
study.

Figure 2.2.Identified
Figure2.
Figure Identified critical
Identifiedcritical plates
criticalplates and
platesand applied
andapplied modifications.
appliedmodifications.
modifications.

Table 1.1.Dishes
Table1.
Table Dishes
Dishestaken
takeninto
taken intoconsideration
into considerationfor
consideration forthe
theplate
platewaste
wasteanalysis
waste analysisin
analysis inphase
in phase111in
phase inthe
in thestudied
the studieddiets.
studieddiets.
diets.
Meal
Meal Item
Item Dish
Dish Dish
DishCharacteristics
Characteristics
Meal Item Dish Dish Characteristics
Drink
Drink Milk
Milk Only
Onlymilk
milk
Breakfast
Breakfast Dessert Drink
Dessert Pastry Milk
Pastry Homemade Only
Homemadepastry milk
pastry
Breakfast ComplementaryDessert Olive Pastry Homemade pastry
Complementary Olive oil,jam
oil, jamand
andsugar
sugar Individual packet
Individual packet
Complementary Olive oil, jam and sugar Individual packet
First
Firstcourse
course Vegetables
Vegetables Without
Withoutsauce
sauce
First course Legumes
Legumes Vegetables Without
Without
Without saucesauce
sauce
Main Legumes Without sauce
Maincourse
course Fish
Fish Cod,
Cod,tuna.
tuna.Without
Withoutbones,
bones,fat,
fat,skin
skinororsauce
sauce
Lunch
Lunch Main course Fish Cod, tuna. Without bones, fat, skin or sauce
Lunch Chicken
ChickenChicken Fried,
Fried,roasted. Without bone, fat, skin or sauce
Fried, roasted. Without bone, fat, skinsauce
roasted. Without bone, fat, skin or or sauce
Red
RedmeatmeatRed meat Grilled,
Grilled, baked.
baked.
Grilled, Without
Without
baked. fat
Without or
fat or sauce
fatsauce
or sauce
Side dish
Side dish
Side dish Warm
Warmside sidedish
Warmdishside dish Vegetables
Vegetables (baked,
Vegetables(baked, grilled)
grilled)
(baked, or
orfried
grilled) fried potatoes
potatoes
or fried potatoes
First
Firstcourse
course Soup
Soup With
Withpasta,
pasta,vegetables
vegetablesor orsemolina
semolina
Dinner
Dinner Purée
Purée Vegetable
Vegetablepurée
purée
Sustainability 2022, 14, 15616 4 of 9

Table 1. Cont.

Meal Item Dish Dish Characteristics

First course Soup With pasta, vegetables or semolina
Purée Vegetable purée
Dinner
Main course Egg Omelette with vegetables or potato
Fish Salmon, hake. Without bones, fat, skin or sauce

The food served and wasted was weighed with a COBOS JCP-30 scale (accuracy 1 g).
The average weight of 5 sample preparations of each of the dishes was considered the
amount of food served to each person per day. The Spanish Food Composition Database [15]
was used to identify the edible weight of each dish. After each service, the trays were
received in the dishwashing area of the kitchen and the waste was sorted according to the
dish and diet. Skin, bones and other non-edible parts of chicken and fish were discarded.
Then, the avoidable waste from the same dish and diet was weighed by conglomerate. The
quantification per dish was repeated for 5 randomly selected days.
The following formulas were used to calculate the plate waste per patient per day (PW
per patient per day) in grams (g) and percentage (%) [16]:
 
n f ood waste i
PW per patient per day (g) = ∑ i=1 /n , (1)
Pi

where:
i: specific day i.
n: total number of measurement days.
Pi : number of patients for day i.
food waste i: food waste for day i.
 
plate waste per patient per day ( g)
PW per patient per day (%) = × 100, (2)
f ood served per patient per day ( g)

where:
food served per patient per day: average weight of 5 sample dish preparations.

2.3. Statistical Analysis

The data were analyzed using the statistical software STATA Version 12. All results
were described with mean and standard deviation. Student’s t-test was used to compare
the plate waste between diets in phase 1 and to compare the waste before and after
the implemented modifications in dishes in phase 2. A p-value < 0.05 was considered
statistically significant.

3. Results
3.1. Phase 1: Plate Waste Analysis before Modifications
The results of the plate waste analysis performed during phase 1 (before modifications)
are shown in Table 2. It must be noted that the number of quantifications on the choice
menu is almost four times smaller for each dish than in the basal diet, since patients
have other options to choose from in each meal. In the case of legumes and chicken, a
statistical analysis could not be conducted because choice menu data were limited (1 day
waste quantification).
Breakfast data were based on the basal diet, since the dishes and serving size were
the same in both diets (patients with choice menu do not have the possibility to choose the
breakfast). Milk was measured in both diets and was ranked as the dish with the highest
waste (29.7% of plate waste per patient per day).
Sustainability 2022, 14, 15616 5 of 9

Table 2. Average quantities of food serving size and plate waste per person per day in dishes from
basal diet and choice menu before modifications.

SS Patient/Day (g) PW Patient/Day (g) PW Patient/Day (%)

Dish Diet n p Value 1
Mean (sd) Mean (sd) Mean (sd)
Breakfast
Milk BD and CM 530 240.3 (9.2) 71.0 (9.88) 29.5 (4.1)
Olive oil BD 355 10.0 (0.0) 2.4 (0.5) 24.3 (4.5)
Jam BD 331 25.0 (0.0) 3.4 (1.3) 13.6 (5.1)
Sugar BD 392 10.0 (0.0) 2.3 (0.1) 22.9 (1.2)
Pastry BD 320 61.2 (2.9) 7.9 (0.7) 12.9 (1.3)
Lunch
Vegetables BD 188 228.1 (38.2) 33.6 (7.6) 14.7 (1.7)
0.49
CM 47 267.1 (7.0) 49.1 (31.1) 18.4 (11.5)
Legumes BD 195 266.4 (54.3) 48.0 (17.4) 17.7 (2.8)
nd
CM 16 271.6 (18.7) 44.3 2 16.3 2
Fish BD 218 151.9 (27.7) 42.7 (14.9) 29.5 (14.6)
0.11
CM 51 130.2 (33.0) 14.6 (13.1) 12.1 (13.4)
Chicken BD 199 166.7 (28.3) 61.0 (41.9) 35.7 (20.3)
nd
CM 9 132.8 (10.9) 64.9 2 63.1 2
Read meat BD 203 102.3 (15.9) 24.4 (17.8) 24.0 (18.6)
0.59
CM 62 113.4 (55.6) 23.4 (21.7) 19.4 (11.1)
Warm side
BD 188 55.2 (23.6) 13.8 (11.0) 21.9 (11.5)
dish 0.90
CM 51 142.8 (42.9) 20.6 (16.0) 20.2 (24.8)
Dinner
Soup BD 214 258.3 (10.4) 153.1 (16.7) 20.5 (6.2)
0.95
CM 85 235.7 (18.8) 48.7 (21.0) 20.8 (9.1)
Purée BD 313 229.5 (22.0) 34.3 (9.2) 14.9 (3.5)
0.56
CM 37 230.7 (24.7) 41.1 (23.8) 18.0 (10.8)
Egg BD 295 148.5 (16.2) 17.3 (9.8) 11.5 (5.9)
0.81
CM 62 170.2 (36.6) 16.7 (12.2) 10.5 (7.7)
Fish BD 211 144.9 (10.1) 31.5 (7.3) 22.1 (6.7)
0.41
CM 69 111.7 (54.1) 9.4 (12.4) 13.5 (18.6)
SS—serving size; PW—plate waste; BD—basal diet; CM—choice menu. n—number of dishes evaluated; sd—
standard deviation; nd—not determined. 1 Student’s t-test. A p value < 0.05 was considered statistically significant.
2 Plate waste determined on only one day.

Lunch and dinner data were analyzed for each diet. In the basal diet, six dishes were
measured at lunch (two first courses, three main courses and one side dish). The highest
PW percentages come from chicken (35.7% patient/day) and fish (29.5% patient/day). At
dinner, four dishes were taken into consideration (two first courses and two main courses).
None of the dishes reached 25% of PW percentage patient/day, with fish and soup being
the highest ones (22.1% and 20.5%, respectively).
No significant differences were found between PW percentages of dishes from both
diets (Table 2). However, the choice menu presents in general a lower PW for each dish,
with the highest observed reduction of PW in the fish at lunch (12.1% versus 29.5%).
From the highest PW percentages found in the basal diet, the dietary department
selected three “critical dishes”: milk, chicken and fish (lunch).

3.2. Phase 2: Plate Waste Analysis after Modifications

The food served and wasted per person per day before and after the implemented
modifications is summarized in Table 3 for each “critical dish”.
The serving size of milk decreased 35 g after the modifications, but only 7.5 g was
removed from the amount of waste generated per person a day. As a result, the PW per
patient per day (%) did not decrease after modifying the individual serving size of milk.
Sustainability 2022, 14, 15616 6 of 9

Table 3. Average quantities of food serving size and plate waste per person per day in dishes of basal
diet before and after performed modifications.

SS Patient/Day (g) PW Patient/Day (g) PW Patient/Day (%)

n p Value 1
Critical Dish Mean (sd) Mean (sd) Mean (sd)
Before After Before After Before After Before After
Milk 530 446 240.3 205.6 71.0 (9.9) 63.5 (21.4) 29.5 (4.1) 30.9 (10.4) 0.81
Chicken 199 114 166.7 (28.3) 228.9 (1.0) 61.0 (41.9) 16.4 (9.3) 35.7 (20.3) 7.2 (4.0) 0.06
Fish (lunch) 218 135 151.9 (27.7) 126.0 (27.5) 42.7 (14.9) 17.3 (11.0) 29.5 (14.6) 12.8 (7.4) 0.06
SS—serving size; PW—plate waste; n—number of dishes evaluated; sd—standard deviation. 1 Student’s t-test. A
p value < 0.05 was considered statistically significant.

Regarding chicken waste, the PW per patient per day (%) decreased in the basal
diet (p = 0.06) after the new recipes were implemented, despite the 62.2 g increase in the
serving size.
Finally, the fish PW per patient per day (%) at lunch was lower after increasing the
variety of the types of fish served, with an average increase in the serving size due to the
variety of fish presentations. Nonetheless, the Student’s t-test analysis did not present a
significant PW decrease.

4. Discussion
The hospital food service designs the patient menus according to their pathology and
particular needs. However, very often patients do not consume the entire menu, which
has a negative impact on their health. In addition, food waste generated at hospitals has a
high economic and environmental impact. In this context, the objective of this study was to
identify which plates are the most wasted in the most extensive diets of a private Spanish
hospital, in order to determine possible interventions to reduce it. It is possible that the
total food waste generated in a private hospital is lower than that produced in a public one,
due to a possibly higher budget for the development of the menus. However, we consider
that the performed approach to recognize dishes with highest losses is valid for both public
and private hospitals.
The quantified wastage on the inflexible ordering system (basal diet) ranged between
11.5% and 35.7% (egg and chicken, respectively). These results are in accordance with
those reported in other hospital studies worldwide [17–23], with an average food waste
between 24% and 56%. However, the difficulty of comparing data between publications
due to variations in the characteristics of hospitals, waste quantification methodology
or food classification must be taken into account. For instance, in the present study,
the measurement of food waste was focused on specific dishes, and consequently, the
determined PW per patient per day referred only to those dishes, which makes it difficult
to compare the obtained results with other studies. These limitations were also noted in
the Food Waste Index 2021 [7], proposed by the United Nations Environment Programme
(UNEP) to unify the waste data for each country and monitor their progress. This proposal
requires quantifying the waste of the total amount of food served in the meals.
Waste does not only vary according to the dish, it also differs according to the possibil-
ity of patient choice [20,24–27]. No differences were observed between the diets, although
in the flexible ordering system (choice menu), the patients have the possibility to choose
what they want to eat according to their appetite and preferences, so it is expected to find
fewer leftovers on the plate. In fact, it has been demonstrated that offering optional menus
is one of the most common and effective approaches to increase consumption and decrease
food waste [13]. Accordingly, the smallest percentages of food waste in the present study
were observed in the choice menu, with a more pronounced difference in the case of fish
dishes (29.5% BD and 12.1% CM at lunch; 22.1% BD and 13.5% CM at dinner). Considering
that fish is not an extensively accepted dish, patients who choose fish (flexible ordering
system) prefer it to other options. Given that the critical items analyzed are a source of
protein, the protein intake of the patients with prescribed CM may have increased, and con-
Sustainability 2022, 14, 15616 7 of 9

sequently, their nutritional status would have improved. Similarly, McCray et al. [27] saw
an increase in patients’ energy and protein intake, accompanied by a significant decrease
in plate wastage when they had options to choose from. Other authors have also been
able to observe directly in surveys [18] or indirectly in their studies [25] how important
it is for patients to have several options to choose their menu. However, Dias-Ferreira
et al. [24] concluded that including a flexible ordering system would not help to decrease
production cost, CO2 emission and food waste as much as implementing a choice between
different portion sizes or offering a bulk service system. Nevertheless, these implementa-
tions require a total modification of the current system in many hospitals and economic
feasibility studies.
According to the established criteria of ≥25% PW patient/day, three critical dishes
of BD (milk, chicken and fish at lunch) were selected for phase 2. Despite the highest
PW percentage observed in the chicken of CM (63.1%), this dish was not included in the
second phase due to a possible overestimated PW. The measured waste corresponded to
only 1 day of quantification and the low number of plates analyzed may have affected
the determined PW percentages. The modifications implemented in phase 2 were based
on suggestions made by the patients and nursing staff, as well as those reported in the
literature. A narrative review on hospital food waste summarized the reasons why patients
do not finish their meals in four categories [28]: poor appetite due to their illness, service
schedules, physical problems such as loss of mobility and the taste and quality of the food.
Therefore, the modifications consisted of the reduction of milk serving size, new recipes for
chicken and higher variety of fish dishes.
The implemented changes reduced the food waste of critical dishes, with the exception
of milk (Table 3). The quantity of served milk was reduced from 240 g to 205 g when
the individual jugs were replaced, while the size of the cups was preserved. A similar
approach was taken on a hospital in Ireland [29], but contrary to our findings, they saw a
44% reduction in milk waste when reducing the amount of milk served in individual jugs.
Given that it is the patients themselves who pour the desired amount of milk and that the
cups have the same capacity, it can be considered that the problem lies in the size of the
cups and not so much in the ration of milk offered in the jugs. For this reason, the Diet
Service has considered replacing the cups with larger ones.
In the case of chicken, the implemented strategy was to offer new, more tasty and
appealing preparations, allowing the decrease in PW values (Table 3). Whereas roasted
chicken has continued to be served, chicken “chilindron” or chicken stew is now more
frequently served. Williams and Walton [28] already sensed the effect that similar in-
terventions could have by classifying them as easy and inexpensive measures to reduce
food waste. In a similar way, Navarro et al. [21] observed a 19% plate waste reduction
after modifying the plate presentation. However, Strotmann et al. [16] did not observe a
reduction in waste when implementing service changes such as more descriptive menus,
raising awareness of waste through posters or modifying rations according to population
group. Given that food-focused actions [21] were more effective than service-oriented
actions [16], it would be advisable to spend time developing new attractive dishes for
patients, including changes in taste, texture and presentation of the dishes. According to
this, the Diet Service increased the variety of fish and culinary elaborations (from two to
seven types served at each meal), resulting in a significant PW reduction.
A periodic food waste evaluation should be implemented in each hospital in order to
identify the specific critical dishes to keep improving the meals and reducing plate waste.
The present study has some limitations such as the evaluation of only part of the diets
served in the hospital, due to the the difficulty of quantifying all the wastes returned in the
trays to the kitchen, even in a small private hospital as in this case. Future studies could
combine food weighing with other novel methodologies, such as visual estimation of food
waste through cameras [30].
In conclusion, a reduction of food waste was observed when implementing specific
modifications to each critical dish, such as new chicken recipes and increasing the variety
Sustainability 2022, 14, 15616 8 of 9

of fish served. Therefore, reduction of food waste in hospitals is possible but it is necessary
to make a diagnosis of the current situation in each center. Identifying critical dishes,
implementing actions to reduce food waste and monitoring progress after implementation
is the ideal process to reduce waste and create a sustainable feeding system.

Author Contributions: Resources, L.G. and C.U.; methodology, investigation and data curation,
C.H., D.S. and L.P.; formal analysis and writing—original draft preparation, L.P.; conceptualization,
supervision and writing—review and editing, R.G. and A.I.V. All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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