Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario,Canada: A grey literature scoping review protocol

Abstract

Background and Aims

The climate emergency and other sustainability challenges interact to threaten human and planetary health. Efforts to improve the sustainability of food initiatives within healthcare institutions could mitigate these threats by addressing the four pillars of sustainability: health, social, economic, and environmental. Understanding current initiatives to incorporate sustainability into food programs and the sustainability pillars that guide those initiatives is important to inform priorities for action. This scoping review will investigate the extent to which major healthcare institutions in Ontario, Canada, have publicly committed to, discussed, planned, and/or implemented sustainable food initiatives.

Methods

The protocol follows guidance from the Joanna Briggs Institute and Arksey & O’Malley. The current strategic plans of 57 healthcare institutions in Ontario, Canada, will be retrieved from their websites and used to examine any commitments to or discussion, planning, and/or implementation of sustainability initiatives. The healthcare institution websites, along with those of selected sustainability organizations, will be searched for grey literature from 2015 to 2024 describing sustainable food initiatives within these institutions. Documents will be screened for eligibility by two researchers. Data concerning the incorporation of sustainable food into institutional food programs, and the sustainability pillars addressed, will be extracted by one researcher, with 10% of entries verified by a second researcher. Data will be shared with stakeholders in sustainability to augment findings. The data will be synthesized narratively.

Summary

This grey literature scoping review will summarize publicly available progress toward integrating sustainable food into healthcare institutions in Ontario, Canada, informing efforts to address climate and other sustainability challenges.

Keywords

Sustainable food climate-resilient healthcare planetary health malnutrition systems thinking protocol

Introduction

Background and rationale

The climate emergency threatens human and planetary health and the systems we depend on for protection (Public Health Agency of Canada, 2022; Romanello et al., 2023). Concurrent social, economic, health, and environmental challenges represented by the Sustainable Development Goals (United Nations, n.d.), interact with the climate emergency to create significant threats to public health. Food and healthcare are also implicated as drivers and potential responses within this complex socio-ecological system (Crippa et al., 2021; Swinburn et al., 2019; World Health Organization, 2020).

Under the 2015 Paris Agreement, 196 countries committed to enact policies to limit global warming to 2°C above preindustrial levels while striving to limit warming to 1.5°C (Lee et al., 2023). In 2023, the Intergovernmental Panel on Climate Change reported that efforts have been grossly inadequate and that if greenhouse gas (GHG) emissions continue at current rates, the world is on track for 2.8°C of warming by 2100 (Lee et al., 2023). Significant physical and mental health impacts from extreme heat, weather events, infectious disease spread, food insecurity, and infrastructure damage are predicted (Public Health Agency of Canada, 2022). Climate modeling suggests the social costs of warming will be felt most acutely in human mortality and agricultural losses (Rennert et al., 2022). These effects will interact with the consequences of disturbing many of the planet's other systems (or planetary boundaries) (Richardson et al., 2023). The modern food system is the primary disruptor of many planetary boundaries including climate change, land-system change, freshwater use, biodiversity, and nitrogen and phosphorous flows (Anastasiou et al., 2023; Campbell et al., 2017; Fanzo and Davis, 2019; Springmann et al., 2018b). The strain on the planet's resources is predicted to increase by 50–92% above present impacts by 2050 from food production and consumption, largely driven by animal-based products and food waste (Springmann et al., 2018a).

Challenges to planetary health are occurring alongside a malnutrition epidemic sustained by the modern food system. Overnutrition, in the form of overweight and obesity, affects more than 2 billion worldwide (Swinburn et al., 2019). Concurrently, undernutrition and micronutrient deficiencies continue in global subpopulations (Swinburn et al., 2019). These trends have led to increasing rates of diet-related chronic diseases such as diabetes, cardiovascular disease, and cancer, which are the leading causes of disability globally, surpassing tobacco smoking (Fanzo and Davis, 2019).

Nutrition and ecology experts have called for a food system transformation to alter the determinants of food environments, facilitating healthier, more sustainable dietary patterns and food systems (Fanzo and Davis, 2019; Hendriks et al., 2023; iPES-Food, 2016; Lieffers et al., 2018; Mason and Lang, 2017; Springmann et al., 2016; Swinburn et al., 2019; TEEB, 2018; Willett et al., 2019). Sustainable diets encompass four pillars (also referred to as principles, dimensions, or categories of sustainability), including health, social, economic, and environmental (Asioli et al., 2020; Fanzo and Davis, 2019; FAO, 2023; Hendriks et al., 2023; Mason and Lang, 2017). According to the Food and Agricultural Organization of the United Nations, sustainable diets have “low environmental impacts… contribute to food and nutrition security and to healthy life for present and future generations… (they are) protective and respectful of biodiversity and ecosystems, culturally acceptable, accessible, economically fair and affordable, nutritionally adequate, safe, and healthy, while optimizing natural and human resources” (Burlingame and Dernini, 2012, p. 7). This holistic conceptualization considers climate and the environment and also includes equity, agency, externalized costs, agricultural livelihoods, disease risk, and leaving a healthy planet for future generations (Burlingame and Dernini, 2012; Mason and Lang, 2017).

Healthcare is also connected to sustainability. An estimated 5% of Canadian GHG emissions originate from healthcare (Eckelman et al., 2018). In 2021, Canada committed to a global agreement to develop climate-resilient, low-carbon health systems (HealthCareCAN, 2023; World Health Organization, 2024). Publicly funded institutions, including healthcare, are responsible for contributing to this international commitment. Healthcare institutions also have a moral responsibility to lead transformations to more sustainable ways of life (Dagenais et al., 2022; Reinhardt and Salvador, 2018; Salas et al., 2020). Part of the impact of healthcare on planetary systems is through food. Healthcare institutions in Canada serve 250,000 meals per day, most of which are procured from large industrial distributors at a total cost of 4 billion dollars per year (Marquez and Gacad, 2019). Initiatives such as the Global Green and Healthy Hospitals Network and the World Resources Institute's Coolfood Pledge indicate awareness of the negative impacts of current food practices within healthcare for sustainability and the need for action (Health Care Without Harm, 2021; Karliner and Guenther, 2011; World Health Organization, 2020). The World Health Organization recommends that healthcare institutions use strategies such as promoting local food production, shifting food menus to limit animal-based products, composting food waste, and creating on-site food gardens using Indigenous plants and seeds when possible (World Health Organization, 2020).

Shifting toward practices that integrate these recommendations could contribute to environmental and economic sustainability by benefitting ecosystems and local economies (Hu et al., 2022; Mason and Lang, 2017; Salas et al., 2020). It would also have benefits for health and social sustainability. For example, a shift to more plant-based foods could enhance nutritional status among patients, staff, and visitors by providing protein, fiber, and essential vitamins and minerals with less sodium, sugars, and saturated fat, eating patterns recommended to reduce the risk of diabetes, cardiovascular disease, and certain cancers (Mason and Lang, 2017; Toulson Davisson Correia et al., 2021). Promoting these dietary patterns through on-site food services and gardens could improve awareness and availability and strengthen local supply chains, regional food security, and equity (Springmann et al., 2016; Swinburn et al., 2019).

According to systematic and scoping reviews conducted to date, there has been limited attention to sustainable food practices in healthcare institutions in the peer-reviewed literature (Alberdi and Begiristain-Zubillaga, 2021; Buller et al., 2023; Carino et al., 2020; Chatzipavlou et al., 2024; Cook et al., 2022; Guillaumie et al., 2020; Rinninella et al., 2023; Soares et al., 2023). Existing initiatives considered in peer-reviewed research do not focus on health but instead on the environmental and economic benefits through strategies such as organic and/or local food procurement, waste audits, recycling, and composting (Alberdi and Begiristain-Zubillaga, 2021; Buller et al., 2023; Carino et al., 2020; Chatzipavlou et al., 2024; Cioci et al., 2016; Cook et al., 2022; Guillaumie et al., 2020; Rinninella et al., 2023; Soares et al., 2023). Sustainability initiatives within healthcare are typically part of institution-wide efforts, not targeted to food, with much of the progress limited to major healthcare institutions in Europe and the United Kingdom (Alberdi and Begiristain-Zubillaga, 2021; Buller et al., 2023; Carino et al., 2020; Chatzipavlou et al., 2024; Cioci et al., 2016; Cook et al., 2022; Guillaumie et al., 2020; Rinninella et al., 2023; Ryan-Fogarty et al., 2016; Soares et al., 2023). Little related research has been undertaken within the Canadian context (Wilson and Garcia, 2011a, 2011b), yet understanding current commitments and initiatives toward incorporating sustainability into food programs within healthcare is needed to identify priorities for action.

Objectives

This grey literature scoping review aims to investigate the extent to which major healthcare institutions in Ontario, Canada, have publicly committed to, discussed, planned, and/or implemented sustainability into food programs. A scoping review is most appropriate because of the broad nature of this issue and the lack of prior synthesis (Arksey and O’Malley, 2005). The specific objectives are to describe how many major healthcare institutions in Ontario have made strategic commitments to incorporate sustainability and/or sustainable food into their operations; to identify how many of these have publicly discussed, planned, or implemented sustainable food initiatives; and to elucidate the sustainability pillars and strategies considered and/or applied within such initiatives. Distinguishing between levels of progress, such as discussing versus committing, will inform the extent to which sustainability has been integrated.

Methods

The scoping review design and reporting were informed by guidance from the Joanna Briggs Institute (JBI, 2024) and Arksey and O’Malley (Arksey and O’Malley, 2005). The review will focus on grey literature because preliminary searches identified that documents discussing efforts related to sustainability within healthcare institutions were more likely to be posted to websites rather than published in peer-reviewed journals. Grey literature also encompasses broader, more flexible formats, allowing a diversity of perspectives that are often more attuned to current healthcare institutions’ operations than academic literature (Benzies et al., 2006; Sedgwick and Ross, 2020). The search strategy was informed by Godin et al. (Godin et al., 2015). Stakeholders will be engaged in the search, which has been identified as an effective strategy for supplementing grey literature search results and integrating knowledge mobilization (Arksey and O’Malley, 2005; Godin et al., 2015). Reporting will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018). This protocol has been registered on the Open Science Framework at the following URL: https://doi.org/10.17605/OSF.IO/CU9P6 and preprinted on MedRxiv at the following doi: https://doi.org/10.1101/2024.09.28.24314378.

Eligibility criteria

The Joanna Briggs Institute's population, concept, and context (PCC) framework guided the inclusion and exclusion criteria (Table 1) (JBI, 2024). The population will include institutions classified by the Ontario Public Hospitals Act (Ministry of Health, 2024) (Online Appendix I) as Group A—general hospitals granted teaching privileges—and Group B—hospitals with no fewer than 100 beds. Documents describing these institutions will be eligible for inclusion (n = 57 institutions) (Ministry of Health, 2024). Institutions with fewer than 100 beds and those providing specialized care, such as rehabilitation or psychiatric care, will be excluded. Major healthcare institutions with larger budgets and a higher number of beds are hypothesized to have more resources to allocate to sustainability-related initiatives, as well as having a wider reach through larger catchment areas than smaller institutions. Documents relevant to campuses of parent health corporations with at least 100 beds will be considered. If few documents related to the sustainability of food programs within these 57 institutions are identified, the scope may be expanded within Ontario as well as to other provinces and territories within Canada.

Table 1.

Grey literature eligibility criteria.

Inclusion criteria	Exclusion criteria
Related to major general healthcare institutions granted teaching privileges and those with no fewer than 100 beds in Ontario, Canada	Describes initiatives in institutions in Ontario, Canada, with fewer than 100 beds and those providing specialized care or in institutions outside of Ontario
Mentions sustainability in the context of institutional food services, including any of the four pillars: health, social, economic, and/or environmental	Does not mention sustainability, or sustainability is discussed in the context of institutional operations aside from food services
Grey literature including reports, press releases, blog posts, newsletters	Peer-reviewed literature, Social media posts on Instagram, Facebook, YouTube, LinkedIn, TikTok, or other platforms
Publicly available online	Access controlled by subscription or membership
Dated between 2015 and 2024	Dated before 2015

Institutional strategic plans

The most recent, publicly available strategic plans of the 57 healthcare institutions, or their parent health corporations, will be eligible for inclusion regardless of whether they mention sustainability or their publication date. Information from these reports will be used to determine the level of progress (commitment, discussion, planning, and/or implementation)—or the lack thereof—toward integrating sustainability into institutional programs.

Information sources and search strategy

The most recent strategic plans available on the websites of the 57 institutions, or the websites of the parent health corporations, will be retrieved. Next, the healthcare institutions’ websites will be searched for grey literature documents that specifically discuss sustainability in the context of food, using the search function within each website. The searches will use terms to capture the PCC (Table 2), with combinations of the search terms applied depending on each website's search capability. The first 25 results for each unique search will progress to the screening stage. For each record, the URL, search terms used, and retrieval dates will be recorded in an Excel (Microsoft Corporation, Redmond, Washington, USA) spreadsheet. Zotero (Corporation for Digital Scholarship, Vienna, Virginia, USA) will be used to manage citations.

Table 2.

Search terms.

Population	Concept	Context
Hospital	Sustainable food	Ontario, Canada
Healthcare institution	Planetary health diet
Healthcare facility	Eco-friendly nutrition
Healthcare centre

Additionally, the websites of seven organizations involved in sustainability in Canadian healthcare institutions will be searched using each website's search function. These organizations include Nourish Leadership, Cascades, PEACH Health Ontario, the Canadian Coalition for Green Health Care, HealthcareCAN, Healthcare without Harm, and Practice GreenHealth (CASCADES, 2023; Health Care Without Harm, 2021; HealthCareCAN, 2023; Nourish Leadership, 2024; Peach Health Ontario, 2021; Practice Greenhealth, 2024. The Canadian Coalition for Green Health Care, 2024). Searching these websites is intended to identify information related to efforts to integrate sustainability in Ontario healthcare institutions that may not have been located on institutional websites. In preliminary searches, documents relevant to the review objectives were located on these organizations’ websites. Combinations of search terms may be used depending on each website's search capability. The URLs, search terms, and retrieval dates for each unique search will be recorded in the Excel (Microsoft Corporation, Redmond, Washington, USA) spreadsheet.

Screening

Duplicates retrieved through the searches will be identified using Excel (Microsoft Corporation, Redmond, Washington, USA) and removed. The strategic plans will automatically proceed to data extraction. As grey literature may not include abstracts or executive summaries, the full text of the remaining retrieved documents will be screened by two reviewers based on the eligibility criteria. Pilot screening of 25 documents will be conducted until an agreement rate exceeding 90% is reached. The remainder of the documents will then be screened independently by the two reviewers, with discrepancies discussed to attempt to reach consensus. If consensus cannot be reached, a third reviewer will be added to allow for a majority decision. The screening result and, if applicable, the rationale for exclusion will be recorded. The URLs, search terms, retrieval date, publishing date, institution(s) cited, document type, and whether sustainable food initiatives were discussed will be retained for all documents (Online Appendix II). A PRISMA flow diagram will summarize all stages of document retrieval, screening, and eligibility for inclusion. A quality appraisal will not be conducted because the purpose of this scoping review is to map the extent of related initiatives rather than assess the methodological quality of relevant documents.

Data extraction

An Excel (Microsoft Corporation, Redmond, Washington, USA) spreadsheet has been developed to guide data extraction (Online Appendix II). Data extraction will be piloted with 10% of the relevant documents by two researchers to ensure that the data extraction fields are accurately charted. The same process for consensus by two reviewers or a majority among three reviewers will be used to resolve any discrepancies. One reviewer will then conduct the remaining data extraction.

For strategic reports, the full documents will be reviewed for discussion of any of the four pillars of sustainability related to any aspect of the institution's operations, including but not exclusive of food. Descriptions of these commitments to sustainability and any descriptions of further discussion, planning, and/or implementation will be extracted.

The remaining documents will be reviewed for evidence of progress toward strategic commitments, such as discussion, planning, and/or implementation, or an intention to incorporate sustainable food initiatives not outlined in strategic plans. Relevant details related to efforts to incorporate sustainable food, including cited institution(s), department(s) involved, intended outcome(s), and/or associated activities, will be extracted (Online Appendix II). If applicable, timelines and any efforts to evaluate initiatives will be recorded.

Stakeholder consultation

Following the completion of data extraction, the Excel (Microsoft Corporation, Redmond, Washington, USA) spreadsheet will be shared via email with stakeholders working to improve sustainability in Canadian healthcare institutions. Preliminary connections have been made with representatives from the sustainability organizations included in the search strategy, which have relevant expertise and experience. Stakeholders will be asked to identify any additional documents relevant to initiatives within the 57 hospitals. Only publicly available documents with no expectation of privacy will be included. Any documents shared will then undergo screening and data extraction according to the procedures above.

Synthesis and presentation of results

Using data extracted from the strategic plans, institutional commitments to incorporate sustainability into overall and food-related operations will be synthesized narratively. Next, using data extracted from the remaining documents, evidence of progress toward commitments and sustainable food initiatives beyond institutional commitments will be synthesized narratively. Evidence of progress will be interpreted based on whether documents describe discussions related to one or more possible relevant initiatives, describe the planning of specific activities toward one or more initiatives or describe the implementation of one or more initiatives. The 57 healthcare institutions will be classified according to whether they have made strategic commitments to incorporate sustainability into food programs, whether they have made progress toward those commitments, the stage of progress, and/or whether they have created sustainable food initiatives not mentioned in strategic commitments. Figures will illustrate frequency counts.

To understand the nature of current initiatives, the sustainability pillars and strategies used will also be synthesized narratively and using charts. This synthesis will draw on details extracted from retrieved documents, including department(s) involved, intended outcome(s), and associated activities. Relevant timelines and evaluation efforts will also be summarized narratively to further inform the extent of progress. The location of institutions discussing, planning, and/or implementing initiatives will be mapped to inform regions of the province with more and less progress. The extent of sustainable food integration will be compared to other provinces in Canada and examples internationally. Any changes to the planned synthesis and presentation approach will be reported in full in the scoping review.

Ethics and dissemination

This research will be a scoping review of publicly available grey literature with no expectation of privacy and no research participants. Therefore, the University of Waterloo's Office of Research Ethics required no ethics approval. Nonetheless, care will be taken not to report identifiable information for stakeholders or persons described in retrieved documents.

Results will be shared with stakeholders in sustainability organizations, as well as at relevant conferences and in peer-reviewed journals, such as the Healthy Cities Conference and the Journal of Canadian Food Studies.

Conclusion

This will be the first grey literature scoping review investigating efforts to integrate sustainable food and describing the most common sustainability pillars and strategies applied within healthcare institutions in Ontario, Canada. While some information may be missed by relying on digital sources, this review is meant to capture the extent of publicly available progress integrating sustainability by distinguishing among commitments, discussion, planning, and implementation. The aim is to compile a broad summary of current efforts in healthcare institutions in Ontario to inform future endeavors to mitigate and adapt to the climate emergency and other sustainability challenges.

Supplemental Material

sj-docx-1-nah-10.1177_02601060251407909 - Supplemental material for Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario, Canada: A grey literature scoping review protocol

Supplemental material, sj-docx-1-nah-10.1177_02601060251407909 for Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario, Canada: A grey literature scoping review protocol by Lisa L Blank, Alyssa D Milano, Lesley Andrade and Sharon I Kirkpatrick in Nutrition and Health

Supplemental Material

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Supplemental material, sj-docx-2-nah-10.1177_02601060251407909 for Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario, Canada: A grey literature scoping review protocol by Lisa L Blank, Alyssa D Milano, Lesley Andrade and Sharon I Kirkpatrick in Nutrition and Health

Supplemental Material

sj-pdf-3-nah-10.1177_02601060251407909 - Supplemental material for Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario, Canada: A grey literature scoping review protocol

Supplemental material, sj-pdf-3-nah-10.1177_02601060251407909 for Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario, Canada: A grey literature scoping review protocol by Lisa L Blank, Alyssa D Milano, Lesley Andrade and Sharon I Kirkpatrick in Nutrition and Health

Footnotes

Acknowledgements

Dr Kirsten M. Lee contributed to conceptualizing this scoping review in its earliest stages.

ORCID iDs

Lisa L Blank

Alyssa D Milano

Lesley Andrade

Sharon I Kirkpatrick

Ethical considerations

This review will use publicly available grey literature with no expectation of privacy and no research participants; therefore, the University of Waterloo's Office of Research Ethics required no ethics approval.

Authors’ contributions

LLB conceived, designed, wrote, and edited the protocol. ADM and LA contributed to the design and editing of the protocol. SIK supervised the conception, design, writing and editing of the protocol, and provided mentorship.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The first author was previously employed as a frontline healthcare provider at one of the healthcare institutions included in the search.

Data availability statement

All data produced in the present study are available upon reasonable request to the authors.

Supplemental material

Supplemental material for this article is available online.

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Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario,Canada: A grey literature scoping review protocol

Abstract

Background and Aims

Methods

Summary

Keywords

Introduction

Background and rationale

Objectives

Methods

Eligibility criteria

Institutional strategic plans

Other grey literature documents

Information sources and search strategy

Screening

Data extraction

Stakeholder consultation

Synthesis and presentation of results

Ethics and dissemination

Conclusion

Supplemental Material

sj-docx-1-nah-10.1177_02601060251407909 - Supplemental material for Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario, Canada: A grey literature scoping review protocol

Supplemental Material

sj-docx-2-nah-10.1177_02601060251407909 - Supplemental material for Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario, Canada: A grey literature scoping review protocol

Supplemental Material

sj-pdf-3-nah-10.1177_02601060251407909 - Supplemental material for Investigating the integration of sustainable food initiatives in healthcare institutions in Ontario, Canada: A grey literature scoping review protocol

Footnotes

Acknowledgements

ORCID iDs

Ethical considerations

Authors’ contributions

Funding

Declaration of conflicting interests

Data availability statement

Supplemental material

References

Supplementary Material