Hospitals prioritise nutritious meals tailored to patients’ needs, and there’s a growing emphasis on offering healthier, plant-based options to reduce environmental impact. Yet, ensuring sufficient protein intake remains vital for patient recovery, particularly for those at risk of malnutrition. This raises the question: Can hospitals meet increased protein requirements while transitioning to plant-based meals, which typically have lower protein quality than animal-based options?

At times, the EWUU alliance generates research with relevance across multiple fields. Such is the case with this project, funded by our colleagues at the institute 4 a Circular Society.

In September 2022, they launched a seed call as part of their Circular Safe Hospitals research line. This call aimed to address the dual challenge of providing both nutritious and environmentally sustainable food in hospitals. This is what led to the transdisciplinary project: “Diets in Dutch Hospitals: setting the scene for healthy, protein adequate, and sustainable menus” of which the results are also very relevant for the i4PH community.

Analysing Protein Quantity, Quality and Environmental Impact

The project’s objectives were multifaceted, encompassing an analysis of protein quantity, quality, and environmental impact across dinner meals served in three Dutch hospitals: Meander Medisch Centum, Ziekenhuis Gelderse Vallei, and UMC Utrecht.

Sander Biesbroek, Assistant Professor Healthy and Sustainable Diets at Wageningen University & Research, underlines the importance of the project: ‘’There has been research into nutritional values in hospital menus, but a detailed view on protein and especially protein quality in combination with the environmental impact was lacking in a Dutch setting.’’

The project’s objectives were twofold:

• Evaluating the protein quantity and quality, as well as the environmental impact, of meals provided in hospitals to identify small menu adjustments that could enhance protein quality.
• Researching how a circular food system could be realised within hospitals, considering stakeholder involvement, procurement strategies, food waste prevention, and reuse practices.

Proteins and stakeholder analysis

Biesbroek: ‘’The project began by meticulously collecting recipe data on total menu’s and dinner meals especially from the three hospitals. Each ingredient was linked to the Dutch Food Composition Table 2016 (NEVO) to determine its nutritional content, focusing on protein. Amino acid composition of the foods were derived from a WUR protein food database.’’

To assess protein quality, the team utilised the protein digestibility-corrected amino acid score (PDCAAS) method. This involved considering factors like protein digestibility and the presence of essential amino acids crucial for human health, aiming to align meal protein content with hospitals’ guidelines of approximately 20 grams of protein per meal.

“In this project we were also able to connect to other research projects. We collaborated with the Alpha project team, who have created a data tool that gives users direct feedback on the protein quality of their meals. We used the tool for assessing the meals and based on algorithms, and it suggested adding or changing ingredients in order to achieve a high protein quality”, adds Biesbroek.

The stakeholder analysis and identification of barriers and opportunities for a more circular and sustainable food system involved interviews with relevant stakeholders of two hospitals. Moreover, environmental impact assessments included factors like greenhouse gas emissions, land use, water usage, and water quality effects, utilising data from the Environmental Impact of Foods database from the National Institute for Public Health and Environment (RIVM).

Important insights

The investigation into hospital meal compositions yielded compelling results. Meals containing animal-based protein demonstrated superior protein content and quality compared to their vegetarian counterparts. Notably, while 85% of animal protein-based meals initially met the 20-gram protein criterion per serving, this dropped to 68% after considering protein quality. Conversely, although 60% of vegetarian meals surpassed the 20-gram threshold in total protein, only 20% met this criterion after factoring in protein quality adjustments.

‘’An examination of amino acid profiles revealed that most animal protein-based meals boasted complete profiles, whereas many vegetarian meals were deficient, primarily in lysine and leucine. Additionally, protein quality was found to be largely influenced by digestibility.”, says Biesbroek.

Furthermore, environmental impact analyses unveiled a significant disparity between animal and vegetarian meals as well, with the latter showcasing approximately 50% lower greenhouse gas emissions (GHGE). Particularly, meals with meat, especially beef, exhibited the highest GHGE. Furthermore, animal protein-based meals incurred greater land use, acidification, and eutrophication of water bodies compared to vegetarian alternatives. Interestingly, blue water use didn’t consistently follow this trend across meals.

Additionally, stakeholder interviews identified challenges in the protein transition, including communication towards patients and staff, financial constraints, and knowledge gaps on protein quality.

Moving forward

So how to proceed, to present healthy, protein-rich and environmentally friendly hospital meals? Biesbroek answers: “Our scenario analyses proposed enriching the meals with lower protein quality scores by incorporating plant-based protein-rich ingredients such as soya flour or dried nori seaweed. These ingredients are just indicative and solely based on amino acid complementarity and without considering for example taste. Furthermore, the role of accompaniments and desserts in enhancing the overall nutritional profile of the meal can be amplified. Providing snacks or desserts within an hour after a meal, for instance, ensures that the amino acid profile of the main meal could be complemented. However, these are just initial steps, and further research is imperative to comprehend all dimensions of optimizing dietary choices.”

The report suggests using more specific product information to study the nutrition, checking what patients actually eat to understand the real health and environmental effects, and seeing how switching to more plant-based meals affects other nutrients’ intake. Additionally patients and hospital staff should be studied to understand what they think about vegetarian meals. Lastly, digital tools could help staff and patients understand the environmental impact and protein quality of the food they’re eating.

Biesbroek concludes, “There is still much research to be done about how we can offer healthy protein-rich meals that also consider a healthy planet. Thanks to this Seed Project, many new connections in different disciplines have been formed. We aim to keep researching these topics together in the foreseeable future by applying for larger research grants.”

Take a look at the complete factsheet on Linkedin Or Download the full report here.

Projectteam

• Sander Biesbroek, PhD (WUR)
• Celia Bannenberg, MSc (WUR)
• J. Marianne Geleijnse, PhD (WUR)
• Pol Grootswagers, (WUR)
• Mariska Lensink, BSc (WUR)
• Yvonne T. van der Schouw, PhD (UMCU)
• Annemieke Kok, MSc (UMCU)
• Brian J. Dermody, PhD (UU)
• Esra Bolat, BSc (UU)
• Gerda K. Pot, PhD (Alliantie voeding in de zorg)
• Iris de Koning, MSc (Alliantie Voeding in de Zorg werk. Ziekenhuis Gelderse Vallei)
• Jelte Kuipers (Meander Medisch Centrum)
• Charlotte Verhage, BSc (Meander Medisch Centrum)

Partners

• Meander Medisch Centum
• Ziekenhuis Gelderse Vallei
• UMC Utrecht
• Alliantie Voeding in de Zorg.