The warm meal ?foodprint? of the UMCG - Rijksuniversiteit Groningen

University of Groningen
CIO, Center for Isotope Research
IVEM, Center for Energy and Environmental Studies
Master Programme Energy and Environmental Sciences
The warm meal “foodprint” of the UMCG
Environmental impact of a hospital food system
Eline Politiek
EES 2013-168 M

Master report of Eline Politiek
Supervised by: Prof.dr. A.J.M. Schoot Uiterkamp (IVEM)
Drs. R. Eenkhoorn (Royal HaskoningDHV)
L.H. Tamming (UMCG)
B. Bennema (UMCG)
Prof.dr. H.C. Moll (IVEM)
University of Groningen
CIO, Center for Isotope Research
IVEM, Center for Energy and Environmental Studies
Nijenborgh 4
9747 AG Groningen
The Netherlands
http://www.rug.nl/fmns-research/cio
http://www.rug.nl/fmns-research/ivem

The warm meal “foodprint” of the UMCG
Environmental impact of a hospital food system
Master Thesis Energy and Environmental Sciences
Author: E.T. Politiek
Published: March 2013
Performed under supervision of Royal HaskoningDHV
Commissioned by the Universitair Medisch Centrum Groningen

Table of contents
I. Acknowledgements ................................................................................................................. 5
II. Samenvatting ........................................................................................................................... 7
III. Summary .................................................................................................................................. 7
1 Introduction ........................................................................................................................... 11
1.1 Problem setting ...................................................................................................................... 11
1.2 Research questions ................................................................................................................. 13
1.3 Methodology .......................................................................................................................... 13
1.4 Boundary setting .................................................................................................................... 14
1.5 Structure of thesis .................................................................................................................. 14
2 About the UMCG .................................................................................................................. 15
2.1 Introduction ........................................................................................................................... 15
2.2 The energy policy and energy use of the UMCG .................................................................... 15
3 Hospital food systems ............................................................................................................ 19
3.1 Three commonly used food systems ....................................................................................... 19
3.2 Current UMCG food system ................................................................................................... 20
3.3 Future UMCG food system .................................................................................................... 21
3.4 Hospitals and food-waste ....................................................................................................... 22
4 Results ................................................................................................................................... 23
4.1 Introduction ........................................................................................................................... 23
4.2 Inflow side ............................................................................................................................. 23
4.3 Inside the hospital .................................................................................................................. 23
4.4 Outflow side .......................................................................................................................... 26
4.5 Environmental impact of the food system ............................................................................... 29
4.6 Outlook to the future: change to decoupled cooking ............................................................... 34
5 Potential hot-spots for the UMCG to reduce their ‘foodprint’ .............................................. 35
5.1 Policy measures ..................................................................................................................... 35
5.2 Technical measures ................................................................................................................ 37
6 Conclusions ........................................................................................................................... 41
7 Discussion .............................................................................................................................. 43
7.1 Research recommendations .................................................................................................... 44
8 References ............................................................................................................................. 45
9 Appendix A – A Belt Cart ..................................................................................................... 49
10 Appendix B – The Autumn Menu 2011 ................................................................................ 51
11 Appendix C – Product categories and product groups .......................................................... 57
12 Appendix D – Methane calculations ..................................................................................... 59
13 Executive summary – The warm meal “foodprint” of the UMCG ....................................... 61

I. ACKNOWLEDGEMENTS
First and foremost I want to my express my gratitude towards my supervisor at Royal HaskoningDHV,
Ronald Eenkhoorn, for enabling me to perform this research. In the past five months, the office at the
Griffeweg in Groningen felt like a second home, thanks to the pleasant interaction with my supervisor and
all the colleagues at RHDHV. I would also like to express my deep gratitude towards Professor Ton
Schoot Uiterkamp for his warm support. He was always very quick with answering questions and giving
feedback at parts of this thesis. Without his effort, this thesis would not have been finished at this
moment. And I would like to thank Professor Henk Moll, who was willing to act as a second supervisor at
short notice.
I would also like to thank my supervisors from the UMCG: Bertha Tamming and Bart Bennema. Their in
depth knowledge about the UMCG was essential for this thesis. They helped me with data gathering and
arranged the necessary permissions. Since no one had looked at the UMCG food system from an
environmental perspective, I find it very courageous of them that they have trusted me in performing this
research. In my view, the experiment has been a great success!
A special thanks to the employees of the UMCG kitchen. During the two days that I observed the
processes in the kitchen, they showed me around and answered all my questions. They have given me a
wonderful insight in the UMCG kitchen that is run by a multicultural and diverse crew, under the
supervision of Marina Stojanovic. I also want to mention the head of the kitchen, Aat Wartena, who has
helped me tremendously with data gathering. Thanks!
Finally I would like to show thank my fellow students. They have been a great support and contributed to
the joy I had in studying during the past two and a half year.
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II. SAMENVATTING
De productie van voeding levert de op twee na grootste bijdrage aan de door de mensheid veroorzaakte
milieu-impact (FAO, 2009). CO2 uitstoot, energiegerbruik, landgebruik en watergebruik zijn allemaal
voorbeelden van die impact (FAO, 2009). Wereldwijd wordt 30% tot 50% van al het voedsel verspild
(Gustavsson et al., 2011, Institution of Mechanical Engineers, 2013). Voor elke calorie voedsel is een
investering van zeven calorieën nodig om het te produceren (Institution of Mechanical Engineers, 2013).
Voedselverspilling kan overal in de voedselketen voorkomen en ziekenhuizen zijn hier geen uitzondering
op. Hoewel het voedingssysteem in ziekenhuizen onderzocht is in de literatuur en in Nederlandse
(algemene) ziekenhuizen, zijn er geen studies beschikbaar (bij mijn weten) die zich richten op de milieuimpact
van het voedingssysteem in een ziekenhuis.
Dit onderzoek heeft als doel om meer inzicht te krijgen in de milieu-impact van de voedsel-gerelateerde
stromen naar, binnen en uit het Universitair Medisch Centrum Groningen (UMCG). De hoofd
onderzoeksvraag is: "Wat zijn de mogelijkheden om de milieu-impact als gevolg van het huidige
voedingssysteem van het UMCG te verminderen?" De nadruk ligt op de warme maaltijden voor de
patiënten. Omdat het voedingssysteem zal worden gewijzigd in maart 2013, biedt dit onderzoek een basis
voor vergelijkingen tussen het huidige en het toekomstige voedingssysteem.
In 2011 werd er 300 ton voedsel ingekocht door het UMCG voor warme maaltijden ten behoeve van de
patiënten. Elke dag worden er ongeveer 700 warme maaltijden bereid. Het voedsel voor deze maaltijden
legt de volgende route af: van de opslag, naar de keuken (waar het koken en portioneren plaats vindt) en
uiteindelijk naar de afdelingen. Op de afdelingen consumeren de patiënten de maaltijd. Het voedselafval
wordt gedeeltelijk op de afdeling weggegooid, de rest gaat terug naar de spoelkeuken. In 2011 werd er
175 ton voedsel (gerelateerd aan de warme maaltijd) weggegooid. Dit is ongeveer 58% van de ingekochte
hoeveelheid met een waarde van € 0,6 miljoen. De warme maaltijden vertegenwoordigen een indirect
energiegebruik van 8900 GJ en een CO2-eq-uitstoot van 789 ton; dat is 1% van de totale CO2-voetafdruk
van het UMCG. Naast voedselafval heeft het UMCG een reststroom vet van ongeveer 100 ton jaarlijks.
De mogelijkheden om milieu-impact gerelateerd aan de warme maaltijden te verminderen zijn
samengevat in de vorm van 'hot-spots'. Dit zijn ofwel beleids- of technische maatregelen, verder
onderverdeeld in korte en lange termijn maatregelen. Deze 'hot-spots' zijn:
Beleidsmaatregelen
• Relatief eenvoudige en korte termijn maatregelen
o Voedsel themadagen organiseren
o Vleesconsumptie verminderen
• Complexe en lange termijn maatregelen
o Overgebleven voedsel doneren aan de voedselbank
Technische maatregelen
• Relatief eenvoudige en korte termijn maatregelen
o Afvalkosten verminderen
o Meters installeren in de keuken
• Complexe en lange termijn maatregelen
o Gebruik maken van milieu benchmarks
o Een Pharmafilter in gebruik nemen
Al deze maatregelen hebben voordelen op gebied van People (bijv. een groen imago, gezonde voeding),
Planet (milieu) of Profit (verminderen van de kosten). De beschreven maatregelen zouden goed passen bij
het voornemen van het UMCG om meer nadruk te leggen op maatschappelijk verantwoord ondernemen.
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III. SUMMARY
Food is the third largest contributor to human-caused environmental impact (FAO, 2009). Food has an
environmental impact on fields like: CO2 emission, energy use, land use, and water use (FAO, 2009).
World-wide 30% to 50% of all food is lost or wasted somewhere along the food-chain (Gustavsson et al.,
2011, Institution of Mechanical Engineers, 2013). For every calorie of food, approximately seven to ten
calories of energy are embodied in that food (Institution of Mechanical Engineers, 2013).
Food-waste can occur everywhere in the food chain, and hospitals are no exception to that. Although the
hospital food system is the subject of research both in the literature and among Dutch (general) hospitals,
there are no studies available (to the best of my knowledge) that focus on the environmental impact of the
food system of a hospital.
This research aims to get more insight in the environmental impact from the food streams flowing in,
within and out of the University Medical Center in Groningen (UMCG). The main research question is:
“What are possibilities to reduce the environmental impact resulting from the current food system of the
UMCG?” The focus lies on the warm meals served to patients. Because the food system will be changed
in March 2013, this thesis gives a baseline for future comparisons between food systems.
In 2011 300 ton food was purchased by the UMCG for warm meals served to the patients. Each day
approximately 700 warm meals are prepared. The food for these meals travels from the storage, to the
kitchen (where the cooking and portioning takes place) and eventually to the wards. At the wards, the
patients consume the food. The food-waste is partially discarded at the ward and partially returned to the
kitchen. In 2011, 175 ton of food attributed to the mean meals was wasted. This is about 58% of the
purchased food, representing a value of €0.6 million. The warm meals served in the UMCG account for
an indirect energy use of 8900 GJ and a CO2 eq emission of 789 ton, which is 1% of the total CO2
footprint of the UMCG. Additional to the food-waste, the UMCG has another waste stream in de form of
grease from grease traps. This is approximately 100 ton each year.
The possibilities for reducing the environmental impact are summarized in the form of ‘hot-spots’ which
are either policy or technical measures, divided in short term and long term measures. These ‘hot-spots’
are:
Policy measures
• Relatively easy and short term measures
o Initiate food theme days
o Reduce meat consumption
• Complex and long term measures
o Donate left-over food to food banks
Technical measures
• Relatively easy and short term measures
o Reduce waste-costs
o Install separate meters at the kitchen
• Complex and long term measures
o Use environmental benchmarks
o Install a Pharma filter
All these measures have benefits either on the People (e.g. green image, healthy diet), Planet (benefits the
environment) or Profit-side (reduces the costs). All the described measures would fit well into the
intentions of the UMCG to put more emphasis on Corporate Social Responsibility in managing the
hospital.
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1 INTRODUCTION
1.1 Problem setting
Food is the third largest contributor to human-caused environmental impact (FAO, 2009). Food has an
environmental impact on fields like: CO2 emission, energy use, land use, and water use (FAO, 2009).
World-wide 30% to 50% of all food is lost or wasted somewhere along the food-chain (Gustavsson et al.,
2011, Institution of Mechanical Engineers, 2013). First of all this is a waste of nutrients, while in certain
parts of the world suffer a shortage of nutrients (WUR, 2012). The production of food world-wide is
currently high enough to provide all the people on this planet with their nutritional needs (WUR, 2012).
But largely due to distribution problems, a part of the world population is undernourished while another
part of the world wastes food or consumes too much (WUR, 2012). Secondly, it is a waste of resources
like energy, water, land, fertilizer and so on used to produce the food (Institution of Mechanical
Engineers, 2013). These resources are invested in the food in multiple stages: from planting the crops till
the cooling trucks that transport the end-product. So for every calorie of food, approximately seven to ten
calories are invested in that food somewhere along the chain (Institution of Mechanical Engineers, 2013).
At the time of writing this thesis, food-waste became a popular topic in the Dutch and international
media. For example, the Centraal Bureau voor de Statistiek (Central Statistics Bureau) calculated the
food waste per person in the Netherlands (CBS, 2011). They expressed the amount of food waste in euros,
to make it more tangible. Many international organizations like the United Nations are cooperating in a
website called “Think, Eat, Save”. The goal of this website is to reduce food-waste worldwide (UNEP,
2013).
The Netherlands has an elaborate waste policy. In the Landelijkafvalbeheerplan 2 (LAP2) the goals to
reduce waste are specified for multiple kinds of waste (Ministerie I&M, 2010). The Dutch government
aims to reduce all food-waste with 20% in 2015 compared to the reference year 1995 (Ministerie I&M,
2010). It is important that this reduction is reached along the entire food-chain: from agricultural
production to the consumer. In total 9.5 million tons of food is wasted in the total agri-food sector
(Ministerie EL&I, 2012, WUR, 2012). By minimizing the food-waste and optimizing the use of foodwaste
streams, the environmental pressure of the total food-chain can be reduced. In order to optimize the
use of food-waste streams, a scale is made that is called the “Moerman’s Ladder” (Ministerie EL&I,
2012). The options for food-waste are (in order of desirability):
1. Prevention (avoiding food-waste)
2. Use for human food (example: food banks)
3. Conversion to human food
4. Use in animal feed
5. Raw materials for the industry (biobased economy)
6. Processing to make fertilizer through fermentation (and generate energy)
7. Processing to make fertilizer through composting
8. Generate sustainable energy
9. Burn the waste (objective: destruction of the waste, and if possible generate power and heat)
10. Dumping in a landfill (this is prohibited for food-waste)
Food-waste can occur everywhere along the food chain, and hospitals are no exception to that. But foodwaste
is not necessarily a focal point for hospitals, since its direct link with the care for patients is not
obvious (Sonnino and McWilliam, 2011). Food itself is a very important issue in the hospital, because it
is associated with the recuperation of the patients. Although food is important for recuperation, the
prevalence of malnutrition among hospitalized patients is at least 20% ((Barton et al., 2000, Grieger and
Nowson, 2007). During hospitalization, the nutritional status of many patients deteriorates, making
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malnutrition an even larger problem (Barton et al., 2000). This means that the patients do not eat enough
to meet their nutritional needs and (involuntarily) lose weight (Goeminne et al., 2012). The deterioration
of the nutritional status of hospital patients often results from a limited appetite of the patient. This can
either be due to illness, but also the quality of the meals, the knowledge of the staff and the atmosphere in
the hospital can influence the appetite of the patient (Snels and Wassenaar, 2011, Sonnino and
McWilliam, 2011). Hospitals often have a patient-oriented view on the food system: the hospital food
system should provide enough nutrients for the patients to recover (Sonnino and McWilliam, 2011).
It can be concluded that hospitals focus mainly on the People-aspect of their food system. On top of that,
the Profit-aspect is important for hospitals. Hospitalization is very expensive and therefore it is very
important to keep the costs as low as possible (Sonnino and McWilliam, 2011). Recently, Sonnino et al.
(2011) claimed that the Planet-aspect should become equally important for hospitals. Hospitals are part of
the public sector and many scientists claim that the public sector should set the example when it comes to
corporate social responsibility (CSR), sustainability and environmental citizenship (Sonnino and
McWilliam, 2011). Of course, enhancing the sustainability of a hospital can be accomplished in many
ways. Reducing the environmental impact of the hospital food system is only one of the options.
Although the hospital food system is the subject of research both in the literature and among Dutch
(general) hospitals, there are no studies available (to the best of my knowledge) that focus on the
environmental impact of the total food system of a hospital. Most studies are patient-centered: how can
the food intake of the patients be improved? Reducing the amount of waste seems an additional effect, but
is never the sole purpose of a study. So especially in determining the environmental impact of the whole
food system in a hospital there is scientific progress to be made. It is important to note that the
organization of a hospital food system is very complex and influenced by many decision makers (Sonnino
and McWilliam, 2011). Therefore the social (and financial) context of the environmental impact of the
food system should also be taken into account in such a research.
In February 2013 a Dutch journal called ‘Food hospitality’ published the results of a food-waste research
at a general hospital in the Netherlands. It reported that in 2011, the amount of food-waste had a value of
€215,000 (Soethoudt and van Garmeren, 2013). Again, the focus of this research was not on the
environmental impact of the food system. But this research does indicate an increased interest in hospital
food-waste and the improvements (both financially as for the environment) that can potentially be
achieved with optimizing the hospital food system.
This thesis gives the results of a study of the environmental impact of the food system at the University
Medical Center in Groningen (UMCG). The UMCG aims to formulate CSR goals for the coming years
and a more sustainable organization of the hospital food system might fit well in these goals. Besides that,
the UMCG has made a multiyear agreement (meerjarenafspraak) with other university medical centers to
reduce their CO2 equivalent emissions with 30% in 2020 (Agentschap NL, 2012, UMCG, 2012c). A CO2
footprint analysis was performed to identify all CO2 emissions from the hospital (DHV, 2011). Till now,
the CO2 emission of the food system was not included in this footprint. The research done for this thesis
provides knowledge about the CO2 emission of the food system. Possibly, changes in the food-system or
in the use of the food-waste stream can contribute to the goals for CO2 emission reduction.
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1.2 Research questions
This research aims to get more insight in the environmental impact from the food streams flowing in,
within and out of the University Medical Center in Groningen. The focus lies on the warm meals served
to patients. In March 2013 the UMCG will switch to another food system, therefore this study is a
baseline study of the current situation.
The main research question is: What are possibilities to reduce the environmental impact resulting from
the current food system (focused on the warm meals served to the patients) of the UMCG?
This leads to the following sub questions:
1. What is the quantity (weight) and quality (which products) of the inflow of food to the
hospital?
2. What are the different routes that the food travels within the hospital?
3. What is the quantity (weight) and quality (which products) of the food-waste leaving the
hospital?
4. What is the environmental impact of the current UMCG food system?
5. Which possibilities are there to reduce the environmental impact of the hospital food system
from the inflow-side?
6. Which possibilities are there to reduce the environmental impact of the hospital food system
within the hospital?
7. Which possibilities are there to reduce the environmental impact of the hospital food system
form the food-waste (outflow-side)?
1.3 Methodology
Observation and informal questioning of staff was used to examine how the food system in the hospital
works. Quantities of the inflow of food in the hospital are retrieved from staff that takes care of the
purchase of the food. Less knowledge from the staff is expected about the quantity and quality of the
food-waste leaving the hospital. So especially on the field of outflow, observation is very important.
Measuring all the waste streams by weighing is not a realistic option; this would take too much time.
When the food flows to, through and out of the UMCG are known, the products were divided into product
groups for an in-depth analysis of the environmental impact. The environmental impact per product group
is calculated with the help of tables available in literature. The processing of these results is performed
with the use of Excel. See for a more elaborate description of the methodology chapter 6 (Results).
The last thee sub questions focus on the potential to reduce the environmental impact from the hospital
food system. These questions are answered with the help of literature and (informal) interviews with
experts within Royal HaskoningDHV, the UMCG and staff of other hospitals.
Eventually, this research leads to an insight in the environmental impact from the food-system of the
UMCG. The results are expressed in the CO2 equivalent (further referred to as CO2eq) emission and the
(indirect) energy use of the food system. Besides that, there is some attention the indirect land and water
use footprint of the food system. The environmental impact of the food system is referred to as the
“foodprint”.
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1.4 Boundary setting
This research is based upon a time investment of 30 credits of the European Credit Transfer and
Accumulation System (equivalent to 21 workweeks of 40 hours). So in order to make research fit within
this period of time, the boundary was set at the main (warm) meals for the patients. Of course, this gives
but a limited view of the hospital food system. Nevertheless, this thesis does provide a methodology that
could be used in further research. This thesis gives a baseline indication of the environmental impact of
the food system of the UMCG. Future changes of the food system in the UMCG can therefore be
compared to the baseline that this thesis provides. This thesis can be seen as the potential start of a series
of researches performed either by the UMCG or by external experts on the hospital food system.
All food-streams (restricted to the warm meals served to the patients) within the hospital gate (entrance
and exit) are within the research boundaries. Outside the hospital gate, information about (products and
processes at) the supplier and the end destination of the waste is also of importance. The extent to which
this information is necessary for this research was determined during the study of the food system in the
UMCG. The data is from the year 2011, since that was the most recent year from which data was
available. Observations are conducted in 2012. Note that all products or product groups are assessed for
their entire lifetime impact, from cradle to grave.
1.5 Structure of thesis
After this introduction chapter, information about the UMCG is given in the second chapter of this thesis.
This information concerns the facts and figures of the UMCG, information about the environmental
policy of the UMCG. In chapter 3, more information is given about the food system of the UMCG and
more general information about hospital food systems. In chapter 4 the results of the research are
discussed. Next some hot-spots for improving the hospital “foodprint” are discussed in chapter 5. In the
following chapters 6 and 7, a conclusion and discussion are given.
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2 ABOUT THE UMCG
2.1 Introduction
The UMCG is one of the largest hospitals in the Netherlands. It has 1339 beds available and the average
time spent in the hospital is 9 days (excluding patients that are hospitalized for day care only; UMCG,
2012a). The UMCG is one of the biggest employers of the northern part of the Netherlands, providing
jobs for over 10,000 people. All Dutch University Medical Centers like the UMCG have three main
functions: care, education and research. It is understandable that the function ‘care’ takes an important
role within the UMCG. Not only do local and regional inhabitants visit the UMCG for their regular
hospital appointments, but people from a larger area visit the hospital for more complex interventions. On
top of that, people from all over the Netherlands visit the UMCG for certain specialties.
The part ‘University’ in the hospital name indicates a role in education and research for the UMCG. As
the name of the hospital already indicates, the hospital is affiliated with a university: the Rijksuniversiteit
Groningen (RuG). The UMCG provides the education of 3400 students from the University of
Groningen, mainly medical students. Other programs that are supported by the UMCG are dentistry and
human movement sciences. Besides these studies, expert training for several medical specialties is offered
at the UMCG. There are approximately 450 physicians in training at the UMCG. In addition, the UMCG
has a role in providing vocational training of nurses, nutritional assistants and other professions that are
operational within the hospital environment.
Together with the RuG the UMCG performs a broad variety of research. Both clinical and fundamental
research is done in collaboration, from molecular biology till long-term population studies. The UMCG is
positioned high in international rankings for research. The main focus point for the combined research
between the UMCG and the RuG is ‘Healthy Aging’ (RUG, 2013, UMCG, 2013).
2.2 The energy policy and energy use of the UMCG
The UMCG aims to reduce its energy use with (at least) 30% in 2020 compared to 2005 (Agentschap NL,
2012). This is part of a multiyear agreement among all UMCs in the Netherlands together with the Dutch
government, focused on energy efficiency. In order to realize such an emission reduction, a road map is
made for all UMCs (Agentschap NL, 2012). This road map includes a forecast towards 2030 (with an
energy reduction goal of 50% compared to 2005), but this is an aspiration for the future and not part of an
agreement.
One of the actions that the UMCG plans to undertake is to develop an energy management vision, which
is scheduled to be released in the end of 2013 (UMCG, 2012c). By working out in detail which actions
have to be taken by which departments or persons in the hospital, the energy efficiency goals can be
achieved. The focus will shift from the technology (abstract) towards the entire chain (practical). At the
moment of writing this thesis, the UMCG works on a greater awareness of the energy ambitions among
employees.
Table 1 - Energy and water use of the UMCG in 2011 (UMCG, 2012c)
Total (direct) energy use 673,5 TJ 1
- Natural gas 14 x 10 6 m 3
- Electricity (purchased) 25 x 10 6 kWh
CO2 equivalent emission 79 x 10 3 ton CO2 eq
Total water use 31 x 10 4 m 3
1 Energy contents as used by the UMCG. Natural gas: 31,7 MJ per m 3 . Electricity: 9,0 MJ per kWh.
15

The UMCG has its own gas-fired power plant. The gas is converted to electricity, steam, and warm and
cold air. The total energy use of the UMCG is depicted in table 1. From table 1 can be concluded that the
gas-fired energy plant of the UMCG does not produce all electricity for the whole hospital. The reason for
this is a financial one: it is cheaper to buy electricity at night at a reduced rate. However, the gas-fired
power plant can supply enough electricity, e.g. in case of a power failure.
To put the energy use of the UMCG in some perspective, the total direct energy use (electricity and
natural gas) can be compared to the direct energy emission of an average (Dutch) household. An average
Dutch household uses approximately 3500 kWh electricity and 1600 m 3 natural gas each year (Milieu
Centraal, 2013). This corresponds with 82 GJ in total 2 . A quick calculation shows that the UMCG uses
approximately as much direct energy as 8,300 Dutch households every year.
All UMCs have commissioned a CO2 footprint analysis in 2010. This CO2 footprint analysis is the basis
of the road map towards 50% energy reduction in 2030. The CO2 footprint analysis is performed by
experts from Royal HaskoningDHV (at that time the company was called DHV). The CO2 footprint
analysis is done for each UMC individually. Because this CO2 footprint analysis is relevant for the results
of this research, it is described here.
All energy used by the UMCG was calculated by using the three scopes that are defined by the
Greenhouse Gas protocol for CO2 accounting (WRI and WBCSD, 2012). These three scopes are:
1. Direct emissions by energy use.
2. Indirect emissions caused by electricity use.
3. Indirect emissions caused by activities of the company.
All greenhouse gas (GHG) emissions were included and converted to CO2 eq emissions using the
greenhouse gas protocol (WRI and WBCSD, 2012). Table 2 gives an overview of the sources of emission
that are included in the three scopes for the specific CO2 footprint study of the UMCG.
Table 2 - Sources of emissions for the CO2 footprint analysis of the UMCG (UMCG, 2012c)
Scope Source of the emissions
1 Natural gas
Fuels for transportation (hospital vehicles)
2 Electricity
3 Transport movements of patients
Transport movements of visitors
Commuting transport of students and employees
Cleaning textile
Business travel by air
Waste processing
Production of materials/items purchased by the UMCG
2 Note that the same energy contents are used as in table 1.
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Figure 1 - The share of each of the three scopes in the CO2 footprint of the UMCG (UMCG, 2012c)
The total CO2 eq emission by the UMCG was 79 x 10 3 ton CO2 in 2010 (and it is assumed that this has
remained about the same in 2011). The third scope accounts for 51% of all CO2 eq emissions of the
UMCG, as can be seen in figure 1. In principle the production of all purchased items should be included
in a CO2 footprint analysis. But this is not done for this specific CO2 footprint analysis. Therefore the
hospital food system is excluded from the calculation. The reason given for this was the expectation that
food would not significantly contribute to the CO2 footprint (this would apply to all purchased items). But
this expectation is not yet substantiated by research.
Within households food products contribute approximately 10% of the total household CO2eq emissions
(Kramer et al., 1999, Munksgaard et al., 2000, Kerkhof et al., 2009). Although a hospital has totally
different (energy) expenditures than a household, it is expected that food items do have a significant
impact on the total CO2 footprint, at least for scope 3.
Since all purchased items are excluded from this CO2 footprint analysis one may assume that the CO2
footprint gives an underestimation of the actual CO2 eq emitted by the UMCG. The UMCG strives to
complete the CO2 footprint as soon as possible. The results from this thesis will be used by the UMCG to
come one step closer to the completion of the CO2 footprint research.
17

3 HOSPITAL FOOD SYSTEMS
This chapter describes the range of possible food systems in healthcare facilities like hospitals that are
currently operational in the Netherlands. After the description of the hospital food systems, the current
system that is operational in the UMCG is explained in more detail. The UMCG will switch to another
system in March 2013; this system is explained in the third subsection. Lastly, an overview is given of the
swill (another word for food-waste) produced by all University Medical Centers in the Netherlands.
3.1 Three commonly used food systems
In general, a food system in a healthcare facility exists of two separate parts: the back-office and the
front-office. The back-office concerns all actions that are carried out without any interference with the
patient. This corresponds with everything that is conducted in the kitchen (the cooking, the portioning,
and so on). The front-office is focused on the client: this corresponds with the delivery of the meals to the
patient. In this thesis, the focus is on the back-office since only procedures in the kitchen have been
observed.
There are three commonly used (back-office) food systems in the Netherlands in healthcare facilities. All
three are explained below and their characteristics are summarized in table 3. The systems are:
1. Coupled cooking (in Dutch “gekoppeld koken”)
2. Decoupled cooking (in Dutch “ontkoppeld koken”)
3. Assembled cooking (in Dutch “geassembleerd koken”)
With coupled cooking the cooking and the portioning (plating of the food) succeed each other directly, as
the name indicates. The prepared food is warm at the moment of plating. The benefit of this system is that
the food is microbiologically safe, because of the small period between cooking and portioning and the
high temperature of the food. One of the big disadvantages of this system is the peak pressure for the
chefs. All food items have to be prepared at a certain time. This makes timing crucial: if items are ready
too soon the temperature of these items will drop (which can promote bacterial growth) and when items
are ready too late, these items cannot be plated.
Decoupled cooking dissociates the cooking from the portioning. Immediately after cooking, the food is
cooled and after cooling, the food items can be stored 72 hours. After portioning, the food can be
regenerated (heated) at any moment necessary. Before the food is regenerated, it is kept cold. This system
releases the peak pressure from the chefs and all kitchen-work can be divided more equally over time,
which makes the overall work of the chefs (and other staff) more efficient. In a coupled system, the chefs
need to cook every day of the week. In a decoupled system, it is possible to cook five days a week.
Especially in labor costs, this can be a great saving. Another advantage of the decoupled system is that up
scaling is very easily achieved. It is possible to cook at one location for multiple healthcare facilities. A
disadvantage of the system is that it requires a large investment to make the kitchen suited for decoupled
cooking. Next to that, the energy use in the kitchen might rise due the extensive cooling of the food and
the areas in which food is portioned.
The third possibility is assembled cooking. In this system, there actually is no cooking at the health care
institution. Instead the meal components are prepared by an external company. The only things the staff at
the health care facility have to do is portion the food components and regenerate the meals. Although the
price per food item might be higher for an assembled component, there is a possible reduction in staff
costs. This makes it attractive to switch to assembled cooking. A disadvantage of the system is that the
food is no longer prepared at the healthcare facility itself, which minimizes the control over the quality
and safety of the meal components. Decoupled and assembled cooking are suited for a combination, since
the meals have to be regenerated in both systems.
19

Table 3 - Summary of key points of the three commonly used hospital food systems in the Netherlands
Coupled cooking Decoupled cooking Assembled cooking
Meals prepared in own kitchen Yes Not necessarily No
Meals need regeneration No Yes Yes
Peak pressure in the kitchen Yes No No
3.2 Current UMCG food system
In order to analyze the potential hot-spots for improvement from an environmental point of view, it is
necessary to understand the relevant aspects of the system. In this section the current food system at the
UMCG is described, from the moment the food arrives at the hospital till the moment the food is either
consumed by a patient or leaves the hospital in the form of food-waste. All information in this subsection
is based on personal observation, informal interviews with the kitchen staff and communication with two
hospital food-experts (Bennema, 2012, Wartena, 2012)
The UMCG currently uses coupled cooking to prepare all warm meals that are served to the patient. Both
breakfast and the evening bread meals are not prepared in the kitchen, but at the wards. Each day, the
kitchen of the UMCG produces approximately 700 warm meals.
Every morning (except on Sunday), fresh food arrives early at the UMCG. The suppliers deliver their
foodstuffs into a cooling cell. The kitchen staff starts every morning around 7:00AM. They start with
cooking various components of today’s menu. How much of every component is needed is estimated the
day before, when the meal choices of all the patients are administrated.
The cooking ends at about 10:30AM, then everything is prepared for the plating. A conveyor belt is used
for plating the patient meals. The meal choice of every patient is reflected on a ‘bandkaart’, translated as
‘belt cart’. This is a chart with the meal choice reflected in a simple way. See Appendix A for an example.
Different colors reflect different meal components (e.g. starch, salad, vegetables, dessert). Within these
colors, a code together with a number reflects the choice (e.g. starch: potato, rice or pasta) together with
the portion-size (e.g. one serving or two). Along the conveyor belt there are multiple stations manned by
one employee, each responsible for one of the components. The plated trays are checked by a supervisor
and then placed in a trolley. These trolleys have a system for contact heating and a separate compartment
for cooling (salad, dessert). The cooling is done by adding a cooling gas (CO2) to the cooling
compartment of the trolley after the trolley is stacked. The trolleys are brought to the basement of the
UMCG, to which all buildings are connected. An electrical vehicle brings the trolleys from the kitchen to
the right department and there nutritional assistants distribute the trays to the patients. Note that the warm
meals are served around noon.
When the patients finish their meals, the trays are returned to the kitchen in the trolleys. There, the food
waste is collected. The dishes are done and the kitchen staff does some preparations for the meal of the
next day. Around 04:00PM everything is cleaned and the staff goes home.
20

Figure 2 – An employee of the UMCG portioning the main warm meals (van Dinther, 2011)
Although the above described logistics might be understandable, there are more factors that are
influencing the food system. First and foremost is the nutritional composition of the meal. The meal
should provide enough nutrients and energy for the patients. On top of that, it should be healthy.
The menu consists of four seasonal cycles. Within a seasonal cycle there is a menu cycle of two weeks.
This means that within a period of two weeks, a patient has a different warm meal each day. And within
the menu of the day, there are multiple choices for all the different meal components. So even if a patient
stays in the hospital more than two weeks, he or she can make different meal choices. Some basic
components are offered each day (like chicken breast, mashed potatoes and apple sauce) because of their
general popularity. Not only the type of food can be chosen, but also the portion in which it is served.
And on top of the menu-variety, certain diets influence the menu as well. Diabetes, food allergies and a
prescribed low sodium intake are only three examples of nutritionally-related disorders that influence the
menu choice. Some patients have problems swallowing solid foodstuffs; they receive soft or mashed
foods. Patients that are malnourished receive an additional set of beverages and foodstuffs in order to
facilitate their recuperation. So on an average weekday the menu consists out of 15 components that each
offers choices with regard to diet and proportion. A summary of the meal choices in the autumn menu
(used in 2012) can be found in Appendix B.
3.3 Future UMCG food system
The UMCG will switch to decoupled cooking in March 2013. The chefs will cook five days a week, while
the other kitchen staff will experience small changes in their working hours. In the future system, the
patients can hand in their meal choice the same day he/she receives the warm meal. The warm meal will
be served in the evenings (around 06:00PM). It is predicted that the operational costs will decrease due to
multiple factors:
• The chefs can work more efficiently and therefore in fewer hours.
• The quantity of wasted food is predicted to decrease, because all meal components can be used
two to three days after cooking.
21

At 01:30 AM the food will be portioned. A difference with the current system is that the food is plated
when it is cold and the plating-room has to be chilled. The trays are placed in the same trolleys as before.
The trolleys are cooled with CO2 and programmed to heat the food 55 minutes before the trays are served
to the patients 3 . The heating will be done at the patient wards. After the warm meals are consumed by the
patients, the trolleys are returned to the kitchen where the food waste is collected and the dishes are done.
3.4 Hospitals and food-waste
Literature shows widely diverging percentages for food-waste in hospitals, but the reported food-waste
lies mostly between the 30% and 40% (Barton et al., 2000, Almdal et al., 2003, Sonnino and McWilliam,
2011, Goeminne et al., 2012). The percentage food waste is calculated by dividing the total amount of
purchased food items (in kilograms) by the amount of swill (in kilograms). This information is not readily
available for all hospitals in the Netherlands. Instead, the quantity of swill can also be expressed per bed.
In this way, hospitals of different sizes can be compared. Because of the specific function of a University
Medical Center, it is best to only compare these hospitals with each other and leave the general hospitals
out. There are 8 UMCs in the Netherlands, but the data of two UMCs was not available for this
comparison. From figure 3 can be concluded that the VUMC and the UMCG st.Radbout score very low
on their amount of swill per bed compared to the other UMCs. Because the data for this graph was
delivered by all UMCs individually, it is possible that the VUMC and the UMCG st.Radbout use a
different way of measuring or reporting their swill (e.g. a part of the swill is discarded with the normal
waste).
22
Figure 3 - Swill from UMCs in 2011 (DHV, 2011)
3 The heating of the trolleys is done with three phase electric power (380 Volt/16 Ampere)

4 RESULTS
4.1 Introduction
This chapter discusses the answers to the first four (sub) research questions. The first three research
questions focus on the food streams in, trough and out of the hospital. The environmental impact of the
food system is determined as an answer on the fourth research question. This chapter ends with an
outlook to the future: what could possibly change in the results described in this chapter when the switch
is made to decoupled cooking?
4.2 Inflow side
The research question that is associated with the inflow side is: “What is the quantity (weight) and quality
(which products) of the inflow of food to the hospital?”
The complete purchase list of food items in 2011 by the UMCG can be delivered upon request at the
IVEM. A summary of the quantity and costs of the products can be found in table 4. “Total food”
includes all food items purchased by the UMCG, for every meal and for patients, staff, and students. The
quantity food items in total is very large compared to the warm meals only, but this is due to the large
number of staff, visitors and students that consume their meals at the UMCG each day. Next to that, all
meals and diet products served to the patients additional to the warm meal are included in “Total food”.
The UMCG has set a budget (2011) of €7,01 per patient per day (Wartena, 2012). This includes all meals
and diet products (if necessary) and adds up to a total of €1.8 million in 2011. Note that next to that, there
are expenses for the food consumed by the staff, students and visitors in the UMCG. These expenses are
reflected in ‘total costs’ in table 4.
To put this in somewhat in perspective: The UMCG had a budget of € 961,7 million in the year 2011
(UMCG, 2012b). The purchased food items for patients only represent 0.2% of the total budget. For
comparison: the total costs of energy in the same year were €9.0 million (0.9% of the total hospital
budget; (UMCG, 2012b).
Table 4 - The quantity and costs of all purchased food items, total and warm meals only (2011)
Warm meals only Total food
Quantity Costs Quantity Costs
Long shelf live 0.07 x 10 6 kg €0.6 million 1.5x 10 6 kg €2.1 million
Fresh products 0.2 x 10 6 kg €0.7 million 1.1 x 10 6 kg €1.4 million
Total 0.3 x 10 6 kg €1.1 million 2.6 x 10 6 kg €3.5 million
All processes associated with the inflow of the food items are described in chapter 5.1 (Day to day
activities).
4.3 Inside the hospital
This subsection answers the research question: “What are the different routes that the food travels within
the hospital?” The day to day activities in the kitchen are described in chapter 5.1. Here a summary is
made of the routes that the foot items for the warm meal travel in the hospital, with a focus on the foodwaste
that arises along the way.
The food enters the hospital in the cooling cells or storage rooms. The food is delivered there by multiple
suppliers, which all have a different origin. When the food is needed, it is used in the kitchen to prepare
the warm meals. Some of the items do not need any processing: fruit, desserts, and so on. These are stored
23

in the cooling cell until they are plated during portioning. A small portion of the food items in storage are
thrown away before they are actually used, as a result of poor inventory control.
Generally, there is a large amount of food left after portioning. Although this food is suited for human
consumption, it is discarded in the swill tank. The plated food goes to the patient wards on trays in
trolleys. There the meals are eaten by the patients. If all patients have finished their meals, the trays are
stored in the trolley again. Although it could not be confirmed by observation or research, it is assumed
that a small part of the food waste is discarded at the ward. The largest part of the food-waste or other
waste (e.g. plastic from the dessert cup) is left on the trays. When the trolleys are returned to the kitchen,
they are unpacked by employees. Most of the food-waste ends up in the swill grinder (connected to a
swill tank). A few specific foodstuffs are not discarded in the swill shredder: banana peels, whole pieces
of fruit, bread and plastic-wrapped food (e.g. desserts, pre-packed salads). Because plastic cannot be
digested, it is logical that wrapped food items are not discarded in the swill shredder. Banana peels, fruit
and bread are left out because they would clog the shredder according to the staff on the floor (Various
employees UMCG, 2012).
Approximately 10% of all the trays are returned to the kitchen untouched (Bennema, 2013). The UMCG
monitors the number of untouched returned trays each year. A patient that does not touch his/her food at
all is a signal for malnourishment, which the hospital wants to prevent as much as possible. Figure 4 is a
picture of an untouched meal that was returned to the kitchen. As can be seen, the fruit (an apple in this
case) is mostly served in a plastic cup to prevent rolling on the tray.
Figure 4 - An untouched tray returned to the kitchen. Food items on the tray: a plate (chicken breast, potato, vegetables),
an apple, two side-salads, dressing and a dessert.
All the food items that are returned to the kitchen are discarded (either in the swill shredder or in a normal
waste bin). This includes untouched desserts, pre-packed salads, salad dressing and so on. Because these
products have reached a temperature above 7°C they are no longer guaranteed to be safe for consumption
and the UMCG is obliged to discard the items (Wartena, 2012).
24

Observation showed that there are four points along the food-chain in which food-waste may potentially
arise:
1. At the storage rooms and cooling cells
2. During cooking
3. During or after portioning
4. After the meal:
a. At the ward
b. Returned to kitchen
A part of the food-waste is unavoidable, for example potato peels. But as much of the vegetables enter the
hospital peeled and chopped, the portion unavoidable food-waste is only small. In this research, no
distinction is made between avoidable and unavoidable food-waste, because it all ends up in the swill
tank.
Figure 5 gives an overview of the food streams to, through and from the hospital. The four points at
which food-waste arises are expressed in their physical location: central storage, central kitchen (during
cooking, after portioning and after the meal returned to the kitchen) and at the patient wards. The largest
part of the waste is discarded with the swill, but another portion is discarded with the normal waste. The
quantity of these waste-streams is discussed in the next subsection.
Figure 5 - A flow chart of the food streams towards, through and out of the UMCG 4 (situation 2012)
4 For an explanation about the additional waste-stream “grease”, see the next subsection.
25

4.4 Outflow side
This subsection answers the research question: “What is the quantity (weight) and quality (which
products) of the food-waste leaving the hospital?” The quantity of the food waste for is published each
year in the annual report of the UMCG. In 2011 this was 182 tons of swill. The quality (which products)
is not known. Observations in the kitchen made showed that a little bit of everything is discarded (see also
previous subsection). In order to make a proper qualitative analysis a sorting analysis should be
performed (but it was not feasible to do a sorting analysis during this research).
The swill from the UMCG is digested with the purpose of producing biogas (van Slochteren, 2013). The
swill tank below the kitchen of the UMCG can contain maximal 8000 Liters swill (van Slochteren, 2013).
The tank is emptied every week. It is transported to Heerenveen, where it is digested. The UMCG has
tenders with different waste management companies for their different streams of waste. Each tender is
contracted for four years (van Slochteren, 2013). The UMCG pays the contractor (which is SITA in the
case of swill) to retrieve and digest the waste. For swill alone, the UMCG pays approximately €15,000
per year (van Slochteren, 2013).
A discussion with a waste expert from the UMCG led to the discovery of another biodegradable stream of
waste (on top of the swill): grease (fat) from grease traps (van Slochteren, 2013). The grease is a byproduct
from cooking that ends up in the waste water (sewerage) and the traps collect the grease before
the water is flushed away with the sewerage. The grease does not have to be monitored and registered.
Therefore it is not mentioned in the annual report. The quantity of grease per year is comparable with the
quantity of swill (approximately 100 tons is assigned to the warm meals; van Slochteren, 2013). And, just
like the swill, the grease is digested. See table 5 for the (theoretical) methane yield of both the swill and
grease.
Table 5- Theoretical methane yield from the swill and grease produced at the UMCG in 2011 (Steffen et al., 1998,
Biowattsonline, 2013)
Swill Grease from grease trap
Total weight (wet) 182, 000 kg 100,000 kg
Total methane 15,500 m 3 7,500 m 3
Total energy content 0.6 TJ 0.3 TJ
See appendix D for an elaboration on the calculations used in table 6. The potential energy yield from
digesting the swill represents approximately 0.13% of the annual use of the UMCG . As a reference, an
average Dutch household uses annually 1600 m 3 natural gas in total (Milieu Centraal, 2013). This
corresponds with 1300 m 3 methane (Milieu Centraal, 2013). So the methane generated by the digestion of
the swill and grease yields enough methane to supply 17 households in their (direct) natural gas need.
Not all food-waste is discarded with the swill. A part of the food-waste (as described in the previous
subsection) is discarded with the normal hospital waste. This normal hospital waste is incinerated; all
hospitals in the Netherlands are obliged to incinerate their waste (van Slochteren, 2013). The incineration
yields electricity and heat.
With all the food and waste streams known, it is possible to expand the flow chard in figure 5 with
quantities. These quantities originate from a combination between the reported quantity swill and
assumptions. Below, a short summary and a visual representation of all food-waste streams are given.
26

Rounded off there was 180 ton swill reported by the UMCG in 2011. It is assumed that 20% of this
amount is water that is added to the swill tank (e.g. during dishwashing). Next to the food-waste
discarded with the swill, it is assumed that an additional 20% is discarded with the normal hospital waste
(e.g fruit and pre-packed food items). These assumptions lead to 175 ton ‘actual’ food waste in 2011.
During observation in the kitchen, it became clear that all the swill the UMCG produces can be attributed
to the main meals served to the patients. All other food-waste (e.g. from the breakfast and bread meal for
the patients, and from the food served to the staff, students and visitors) is discarded with the normal
waste. This means that from the 300 tons purchased food items for the warm meals; 175 tons or 58% was
wasted in 2011 5 . With 700 meals served each day, this corresponds with approximately 650 gram waste
per meal every day in 2011. This amount of food-waste has a value approximately €2.30 per warm meal.
Reducing the amount of food-waste per patient means that the budget per patient can be spent more
efficiently on warm meals.
Figure 6 - Food waste at the UMCG, converted in the weight of food and waste per meal (2011)
Table 6 - Value of the food (warm meals for the patients only) and food-waste in 2011
Weight in 2011 Associated costs in 2011
Food items for meals 300 tons € 1,1 million
Food-waste 175 tons €0.6 million
Knowing the amount of food waste is known and the places at the hospital where it arises, the flow chart
from figure 5 can be expanded with the quantity of the food-waste. First, the assumptions are summarized
in table 7. These percentages are used to make figure 7. In this figure, all places where food-waste arises
are present along with the amount of food-waste (in percentages) that arises at this place.
5 Note that the total percentage of food waste from the UMCG will be lower, because all other food waste is not
registered (so the total food waste does not increase) and the total quantity of foot items purchased by the UMCG is
higher than 300 tons.
27

Table 7 - Summary of assumptions about the origin and destination of the food-waste 6
Swill Normal waste
Storage - 5%
Kitchen (cooking) 10%
After portioning 50%
At the ward 5%
Returned to the kitchen 20% 10%
Total 80% 20%
28
Figure 7 - Indication of where the food-waste originates and the quantity of the food waste in percentages.
The abbreviation N.W. stands for Normal Waste.
6 There is no actual determination of the weight or statistical analysis involved with these assumptions. All
assumptions are based on observations.

5 ENVIRONMENTAL IMPACT OF THE FOOD SYSTEM
This last subsection answers the fourth research question: “What is the environmental impact of the food
system?” First, the methodology for calculating the environmental impact is explained. The results are
given in the next subsection. Next to the calculation of the indirect energy use and the CO2 eq emission,
the indirect land en water use by the UMCG food system is determined. The latter two analyses are not
explicitly included in the research questions, but during the research it was assumed that the analysis of
the indirect water and land use would add value to the calculation of the environmental impact. The
results of those two analyses are given in the last subsection.
5.1.1 Methodology for environmental impact calculations
Because the UMCG already had information about the total energy use at the hospital (expressed in MJ)
and the CO2 footprint of the hospital, it was a logical choice to express the environmental impact of the
food system in MJ (indirect energy) and CO2 eq. Both were calculated by using the purchase lists over
2011, only using the products that were consumed during the warm (patient) meals.
Note that not all direct energy use related to the food system (e.g. in the kitchen, at the wards) is included
in this research. The same holds for the way the food waste is processed. Both direct energy use by the
UMCG and waste processing are already included in the CO2 footprint analysis. Next to that, transport of
food and waste is not taken into account. This is omitted from the CO2 footprint that was made for the
whole UMCG and therefore also omitted in this research.
The purchase lists contained information about specific aspects of a product (most of the times this
included the weight or volume), the quantity in which it was bought and the price of the products.
Because the methodology for the calculation of the environmental impact required the weight per product
(group), the weight of each item was derived from the product information. Drinks and supplementary
diets products were excluded from the list. Fruit and desserts were included, because these products are
served to the patients during the warm meal.
After this, the list was categorized in seven product categories. Each product category exists of either one
or multiple product groups. These are listed in table 8. The complete purchase list of the UMCG can be
delivered upon reques at the IVEM. This list is in Dutch, because it was delivered in Dutch and
translating would not add significant value to this thesis.
By means of tables derived from literature, it was possible to calculate the indirect energy use in MJ and
convert this to the CO2 eq emission (Gerbens-Leenes, 2003). In order to explain the methodology
thoroughly, it is described step by step accompanied with an example.
1. All food products for the main meal were selected and categorized in seven product categories
and subsequently in a product group (see table 8).
Example: product category 2, potatoes vegetables and fruit. From this category, the product
group “Potatoes” will be used in this example. This product group adds up to a mass of 35 x 10 3
kilogram.
2. For each product group, an equivalent is searched for in the table provided by Gerbens-Leenes
(2003).
Example: the item “Potatoes (plastic bag)” is used for the product group “Potatoes”. The
corresponding value from the table provided by Gerbens-Leenes (2003) is 1.9 MJ/kg.
3. The indirect energy use of the product group is calculated by multiplying the total weight of the
product group with the value from Gerbens-Leenes (2003).
Example: for the product group “Potatoes”: 35 x 10 3 x 1.9 = 66.7 x 10 3 MJ
29

30
4. The amount of indirect energy is converted to CO2 eq emission. The indirect energy is assumed to
be diesel used in agriculture or transport 7 . The conversion factor is recommended by an expert
from the Groningen University (Benders, 2013). Each MJ indirect energy represents a CO2 eq
emission of 0.09 kilogram.
Example: for the product group “Potatoes”: 66.7 x 10 3 MJ x 0.09 = 6.0 7 x 10 3 kilogram CO2
eq.
Appendix C shows all choices from the list used by Gerbens-Leenes. The indirect energy use and CO2
results are given in the next subsection of this chapter.
Table 8 - Product categories and product groups used to calculate the environmental impact of the UMCG food system
Product categories Product group
1. Bread, pastry and flour products Flour (including bread)
Rice
Pasta
Potato starch
2. Potatoes, vegetables and fruit Dutch fruit (apple, pear)
Tropical fruit (incl. canned fruit)
Greenhouse vegetables
Open ground vegetables
Potatoes
3. Beverages and products containing sugar Sugar, sweeteners, sugar syrup
Honey
Fruit juices (used for cooking)
4. Oils and fats Vegetable oils and fats
5. Meat, meat products and fish Pork
Beef
Poultry
Fish
Other meat (e.g. lamb)
6. Dairy products and eggs Desserts
Cheese
Cream
Eggs
7. Other products Salts, herbs, broth powder
Sauces
Meat substitute
Composed meals ready-to-eat
Canned tomatoes
Remaining products (no category applicable)
7 This assumption might not be entirely correct, but justified because it gives a representative indication.

5.1.2 Lifetime energy use and CO2 emission
The results expressed in indirect (primary) energy use and CO2 eq emissions are listed in table 9. Because
the CO2 eq emission is calculated directly from the indirect energy use, all graphs using percentages are
expressed in CO2 eq emission (percentages would be equal for indirect energy and CO2 eq emission). The
CO2eq emission is compared to the CO2 footprint of the UMCG.
The total indirect energy used by producing the food items that are used for the mean meals for patients at
the UMCG is 9 TJ. This is 1.3% of the total (direct) energy use of the UMCG in 2011. The CO2 eq
emission is 798 ton, corresponding to 1% of the CO2 footprint analysis of the UMCG.
The food items should be classified in the third scope of the CO2 footprint (indirect emissions caused by
activities of the company). The food items account for 2% of the third scope, as shown in figure 8.
Table 9 - Total indirect energy and CO 2eq emission from the warm meals served to the patients at the UMCG in 2011
Total indirect energy 8914 GJ or 9 TJ
Total CO2eq emission 798 ton
Figure 8 Scope 3 from the UMCG CO 2 footprint including the warm meals (2% of total in scope 3)
31

The CO2 analysis of the different food categories used in this thesis can be seen in figure 9. The left-hand
panel shows the food categories in weight, displaying that category 2 (vegetables and fruit) has the largest
share. The right-hand panel shows the CO2 emission in the different categories. Now category 5 (meat)
has the largest share in the total. This is to be expected, since the environmental impact from meat
products is relatively high compared to other food products (de Vries and de Boer, 2010).
The results from the environmental impact analysis do not correspond with the expectation that the food
items could possibly account for up to 10% of the total CO2 eq emissions of the UMCG. The possible
explanations for this discrepancy are elaborated upon in chapter 9 (Discussion).
Figure 9 - The product categories for the warm meal divided by weight (left) and CO 2 footprint (right).
5.1.3 Environmental impact: land and water footprint
Environmental impact is broader than CO2eq emission only. In addition to the indirect energy (and CO2eq
emission) research, information about the land and water footprint of the food items for the warm patient
meals are collected. Information about the land use was available in the same source that was used to
determine the indirect energy use (Gerbens-Leenes, 2003). The information about the water use is
obtained from a website specialized in water footprint of food (and other agricultural) products
(Mekonnen and Hoekstra, 2010). For direct land use, the total surface area of the UMCG is used (UMCG,
2012a). The direct water use by the UMCG is also given in the annual report (UMCG, 2012a).
32

Table 10 -The land use and water footprint for the UMCG, both direct (whole UMCG) as indirect (food only) in 2011
UMCG (direct) Food footprint (indirect)
Land use 35 x 10 4 m 2 90 x 10 4 m 2
Water use 31 x 10 4 m 3 50 x 10 4 m 3
As can be concluded from table 10, the food footprint for land use is approximately equivalent to three
times the (surface) area of the UMCG. The water footprint is almost twice as large as the direct water use
by the UMCG. Category 5, meat, has the biggest contribution to both the indirect water use as the indirect
land use. See figure 10 for a representation of all the product categories in the water and land footprint.
Figure 10 - The product categories for the warm meals divided by indirect water use (left) and indirect land use (right).
33

5.2 Outlook to the future: change to decoupled cooking
The UMCG is to switch to decoupled cooking in March 2013. In this subsection presents an outlook into
the future, what could possibly change in the results described in this chapter when the switch is made to
decoupled cooking?
Less food-waste
Because all prepared food components will be cooled and therefore preserved for a longer period, it is
expected that the amount of food-waste after portioning will drop significantly. The food that is left over
after portioning can be used again the other day or at another location (e.g. the kitchen that prepares meals
for staff, students and visitors).
Higher energy use in the kitchen
The energy use at the kitchen is predicted to rise. This rise is attributed to the cooling of the food
components and the area used for portioning. There are other changes in the kitchen that might reduce the
energy need of the kitchen (e.g. cooking with steam instead of natural gas), but these reductions are
forecasted to be smaller than the increase in energy use at the kitchen (Bennema, 2012).
Higher energy use at the wards
Because the food is going to be regenerated at the wards for 55 minutes, the energy use at the ward will
rise due to the change to decoupled cooking.
Increased capacity of the kitchen
Shortly after the switch to decoupled cooking, the UMCG kitchen will increase the production of warm
meals with approximately 25% (Bennema, 2012). All warm meals for the rehabilitation facility
‘Beatrixoord’ in Haren (part of the UMCG) will be produced at the UMCG kitchen. This increase in
capacity will increase the energy use at the UMCG. But since the kitchen at Beatrixoord shall be closed
and a higher efficiency can be realized due to the increased capacity, the net energy use per meal is not
predicted to rise. The amount of food-waste produced at the UMCG does possibly rise as a consequence
(but again, the net amount of food-waste per meal will probably decrease because of the higher
efficiency). Because all the meals have to be transported from the UMCG to the Beatrixoord, the transport
will increase (with the corresponding energy use and CO2 eq emission).
In chapter 7 recommendations for further research are made. Part of this recommended research is
focused on studying the environmental impact of the future food system at the UMCG.
34

6 POTENTIAL HOT-SPOTS FOR THE UMCG TO REDUCE THEIR ‘FOODPRINT’
This chapter answers the main research question: “What are possibilities to reduce the environmental
impact from the current food system (focused on the warm meals to the patients) of the UMCG?” The
contribution of the CO2eq emission from the food system is relatively small compared to the UMCGs’
total CO2 footprint. But this does not mean that any actions lowering the environmental impact from the
food system will have no result. First of all, environmental impact consists of more parameters than
CO2eq emission only. The indirect water en land use footprints from the food system are quite high and
can be lowered. Secondly, if one looks at the food system and the UMCG from a sustainability point of
view, there are more actions that can be taken. Some actions might enhance the People-side (e.g. more
healthy meals, a ‘green’ image) whereas other actions might lower the costs (Profit-side). Both actions on
the People and the Profit side can benefit the environment (Planet side). Below is explained how these
three sides can work together to create a healthy and environmentally friendly UMCG without rising
costs. The potential hot-spots are divided in policy measures and technical measures. Both types of
measures can be further divided in easy measures, that can be accomplice on the short term (< 5 years)
and more complex measures that take a longer time to be implemented (> 5 years). The hot-sports are
summarized in figure 11.
6.1 Policy measures
Policy measures are measures that require either a change in the UMCG policy or an intention towards a
certain hospital image (e.g. a sustainable hospital). The more complex and long-term measures involves a
measure that is harder to establish because of the current laws and regulations in the Netherlands.
6.1.1 Relatively easy and short term measures
Food theme days
Food theme days were organized previously in the UMCG, e.g. meal prepared by chef Dick Soek (van
Dinther, 2011). He used local products to serve all patients in the hospital a healthy and mainly organic
meal. More and more healthcare professionals are worried about the food served to their patients
(Hermens, 2012). Although food is only a small percentage of the total budget, it has to be as efficient
(money-wise) as possible (van Dinther, 2011). And especially food can be very important for the health of
a patient. In the light of ‘Healthy Ageing’, one of the research pillars of the UMCG, food is very
important (RUG, 2013, UMCG, 2013). Healthy food can work preventive for many lifestyle diseases like
diabetes or obesity (Popkin and Gordon-Larsen, 2004). Regional products can contribute in a healthy diet
(van Dinther, 2011). There is no conclusive scientific evidence that organic and regional products have
specific health benefits, but often regional products taste better, are fresh and organically or otherwise
environmentally friendly grown (Hermens, 2012). Especially the taste can help to reduce the quantity
food that is returned to the kitchen (Hermens, 2012). If a meal is very tasty, patients are more inclined to
finish their plate.
These benefits are on the People-side and the regular organization of theme days with regional food with
give the UMCG a more sustainable image. This can further improve the way patients (and health
insurance companies) appreciate the UMCG.
On the Planet-side, there are also benefits from purchasing regional foods. These food items have a
shorter transporting distance to the hospital, which lowers the CO2eq emission (Pretty et al., 2005,
Hermens, 2012). Although the transporting distance is not (yet) included in the CO2 footprint, this should
be an item of interest in the future. Next to that, most regional products are from open ground cultivation,
which has less CO2 eq emission compared to greenhouse cultivation (Gerbens-Leenes, 2003). Mostly,
regional products have an additional benefit for the environment: they are mostly cultivated extensively
(Hermens, 2012). This can either mean organically grown or another method that is focused on the most
35

environmentally friendly way to cultivate (instead of intensive agriculture, which is focused on
maximizing the yield; Gomiero et al., 2011).
In short, food theme days could result in improvements on both the People and Profit-side. Although not
mentioned yet, the Profit side does not have to be compromised (Hermens, 2012). Regional products do
not have to be more expensive than conventional products, because they can be bought from the farmer
directly (instead of from a retail company) so it saves in overhead costs (van Dinther, 2011).
6.1.2 Complex and long term measures
Reduce meat
All offered portions for the meal components are ordered in half size portions 8 . Twice such a portion is a
normal serving of for example meat, potatoes or vegetables. One half size portion of meat is 65 grams.
Most people order a complete serving, which adds up to 130 gram. The Dutch center of nutrition advises
a serving of meat of 100 – 125 grams a day, including meat cuts that are served on bread, fish and eggs
(Voedingscentrum, 2012). Next to that, they state that it is perfectly acceptable (from a health
perspective) to exclude meat from the main meal once or twice a week (Voedingscentrum, 2012).
The reduction of meat in the meals could be done in multiple ways. Some examples are:
• Encourage patients to only take half a serving of meat each meal.
• Reduce the half serving of meat to for example 50 gram. One complete serving would then weigh
100 gram, which can be supplemented with meat cuts on bread.
• Encourage patients to order fish twice a week.
• Encourage patients to not order any fish or meat with their warm meal once a week, for example
by offering a healthy alternative based on vegetable proteins. Use the same day for this every
week, e.g. Meatless Monday (in Dutch: Plantaardige Maandag; Meatless monday, 2013).
The dietary advice to the UMCG to reduce the meat consumption of the patients might be a sensitive
advice. This is mainly due to malnourishment of some patients. Especially malnourished patients can
benefit from the protein in meat (Barton et al., 2000, Goeminne et al., 2012). So although the general
advice is to reduce the meat consumption of the patients, the nutritional assistants should keep in mind
that malnourished patients might need another approach. As with the previous hot-spot, reducing meat
might have benefits on the field of ‘Healthy Aging’ (UMCG, 2013).
Reducing the meat consumption of the patients has benefits on the field of People, Planet and Profit. First
of all, it can be healthy (especially in overweight patients) to reduce the intake of animal protein (Popkin
and Gordon-Larsen, 2004). Secondly, meat has a high environmental impact per kilogram compared to
vegetable proteins (Gerbens-Leenes, 2003). So by reducing the amount of meat bought by the UMCG, the
CO2 footprint from the food system can be reduced. Third, meat is quite expensive per kilogram.
Reducing the amount of meat will also reduce the costs per meal.
Donate left-over food to food banks
There are two distinct streams of food waste that could have potential benefit for a food bank. These two
streams are:
1. The food that is left over after portioning and is discarded with the swill.
2. The untouched pre-packed foot items that are returned to the kitchen.
The first stream will theoretically be minimized by the decoupled cooking, which will be implemented
shortly after the publication of this thesis. Families that are affiliated with the food bank in Groningen
could come to the hospital when the portioning is finished. If they bring microwave containers, they could
fill these containers with enough food for one evening meal for their family. Observation in the kitchen
8 With the exclusion of pre-packed components like salads, desserts and fruits.
36

led to the assumption that approximately 50 people can be fed daily with the food that is left over after
portioning (provided that they do not have any preferences for certain food items).
The second waste-stream is more difficult to use for consumption according to the laws and regulations in
the Netherlands. The untouched pre-packed food could be collected when the food trolleys are returned to
the kitchen. But this food items have all reached a temperature above 7°C and are therefore excluded
from consumption. Besides that, all products that have been at the wards should be incinerated according
to the Dutch law (van Slochteren, 2013). This makes the use of the second waste-stream a bit more
challenging, but it could certainly be worth investigating the possibilities.
Using the waste-stream of food for human consumption is the highest that can be achieved according to
the Moerman's Ladder (see Chapter 3, Introduction). So this hot-spot has potential benefits on the Planetside.
But also on the People-side, because donating leftover food to the food banks can mean a lot to the
less fortunate people in Groningen.
6.2 Technical measures
6.2.1 Relatively easy and short term measures
Reduce waste costs
Some streams of waste can be very valuable, like the swill and grease from the UMCG. Both are used to
generate sustainable energy (biogas or/and electricity). With this knowledge, the UMCG could use the
next waste-tender negotiations to negotiate about a reduction of the waste costs (and maybe even
eliminate the costs).
This measure only has a benefit for the UMCG on the Profit-side.
Install meters
At this moment, there are no separate meters for gas, electricity and water use installed at the kitchen.
This means that the specific energy and water use by the kitchen cannot be monitored. Installing meters
would not only give insight in the use of energy and water, but would also be a good base for reducing the
use of energy and water. When it is known how much the kitchen uses, future goals can be made to
reduce the use of energy and water. There are many systems available that make it relatively easy to
install digital meters, e.g. Plugwise (Plugwise, 2013).
This measure has benefits on the Planet-side (reduction in the use of resources) and Profit-side (the costs
will be reduced if the energy/water use is reduced).
6.2.2 Complex and long term measures
Use environmental benchmarks
All hospitals in the Netherlands have to report each year about the state of their hospital in the past year.
Not only financial, but also environmental and social. Although all hospitals have to report roughly on the
same parameters, these annual reports differ very much between hospitals.
A more transparent way would be that all hospitals use the same format or benchmarks in their annual
report. The UMCG could choose multiple benchmarks in which it wants to express their influence on the
environment (for example: energy use per m 2 or water use per m 2 ). Some of the parameters could be
expressed per hospital bed (e.g. the swill, see figure 4). The University of Groningen already uses this
methodology to monitor their environmental performance (de Jager et al., 2003). The Global Reporting
Initiative can provide guidelines on reporting the sustainability parameters (GRI, 2013). These guidelines
are clear, available online and based on the principle that all companies and institutions world-wide
should adopt a similar way of’ sustainability reporting’.
Some other hospitals use a benchmark that is called the “Milieu Thermometer Zorg” (Environmental
Thermometer Care), which is a special program developed to decrease the environmental impact of a
hospital (Milieuplatform Zorg, 2012). It is a possibility for the UMCG to participate in this benchmark.
37

Comparisons between the participating hospitals are very clear, since all participating hospitals have to
report in the same format (Milieuplatform Zorg, 2012).
This measure is complex and long-term because this measure is only fully effective if all UMCs (and
even better, all hospitals) use the same way of monitoring their environmental impact. In that way, UMCs
can compare their performances with the performances of their peers. The way the environmental
performances are monitored now is not very insightful (UMCG, 2012c). The reason for this is that it all
remains rather abstract. Using the same benchmarks between hospitals could give more practical and
tangible view on the performances of a hospital.
Installing a pharma filter
The Pharma filter is the name for a collection of measures in and outside of the hospital that has as a main
goal the purification of hospital waste water (van den Berg, 2013). This waste water is often contaminated
with drug residues (ranging from hormones to cytostatic drugs) which end up in the common municipality
sewer. Since the concentrations of the drugs in the sewer water are very low because of dilution in the
sewer, most of it cannot be retrieved again from the water at water treatment plants (van den Berg, 2013).
The Pharma filter is based on a closed loop, and all waste water is purified before it is eventually
discharged on the common sewer (van den Berg, 2013). Next to that, almost all waste (even hazardous
and hospital waste) can be discarded with the sewerage as well. There are two different processes in the
Pharma filter:
1. Purification of the waste water
2. Digestion of the waste and decontamination of the residual
A feasibility study of the Pharma filter was performed by an employee of the UMCG (Tamming, 2013).
A summary of her conclusions:
• The digestion of the waste would not yield enough energy to keep the Pharma filter running.
Additional energy would be needed.
• Overall there is no net saving in energy or CO2 eq emission.
• The Pharma filter would require a area of 1,300 m 2 , with a maximal height of 6 meters.
• The theoretical payback time would be around 10 years.
Although the energy use and CO2 eq emission could rise slightly theoretically when installing a Pharma
filter, there are some other advantages for the environment. The most substantial one is the purification of
the waste water (van den Berg, 2013). At the moment of writing this thesis, there are no guidelines about
the amount of certain toxins in waste-water (e.g. estrogens). It is expected that guidelines will be
introduced in the near future (van den Berg, 2013). So Then, the theoretical payback time is predicted to
drop. Besides this, the feasibility study does not go into detail about the importance of other sustainability
criteria other than energy use and CO2 eq emission (e.g. Corporate Social Responsibility).
38

Figure 11 - Potential measures the UMCG could take either on the People-side, Planet-side or Profit-side.
39

7 CONCLUSIONS
This chapter discusses all conclusions in the same order as the research questions, followed by the answer
on the main research question.
1. What is the quantity (weight) and quality (which products) of the inflow of food to the hospital?
In the year 2011 the UMCG purchased 300 tons of food to provide a warm meal to approximately 700
patients daily. These products are classified in seven product categories; each category is further divided
in one or multiple product groups. This classification can be seen be in table 8, chapter 4 (Results).
2. What are the different routes that the food travels within the hospital?
Inside the hospital the food travels along the following route:
1. Storage rooms and cooling cells
2. Kitchen for cooking
3. Portioning
4. Patient wards
5. Returned to the kitchen for dishwashing
The end-destination of the food is either the patient (42%) or it is discarded (58%).
3. What is the quantity (weight) and quality (which products) of the food-waste leaving the hospital?
In 2011 the UMCG reported approximately 180 ton of swill. Observations at the UMCG made it clear
that this quantity is entirely attributable to the warm meals served to the patients. Besides that, a fraction
of the biodegradable waste is discarded with the “normal waste”, which is incinerated. After subtraction
of the amount of water added to the swill and addition of the amount of food-waste that is discarded with
the normal waste, the quantity of food waste in 2011 is assumed to be 175 ton. Food-waste arises at all
locations along the way the food travels through the hospital. Next to food-waste, there is an additional
stream of waste: grease from grease traps. This stream accounts for 100 tons each year. For a visual
representation of where the food-waste arises and with which quantity, see figure 7, chapter 4 (Results).
4. What is the environmental impact of the current UMCG food system?
The food items for the patient warm meals accounted for an indirect energy use of 8,900 GJ and a CO2 eq
emission of 789 ton. The latter represents 1% of the total UMCG CO2 footprint. This means that the CO2
eq emission is not very visible compared to the total CO2eq emission by the UMCG. Despite that, the
amount of indirect land and water used for cultivating these food items is respectively 250% and 160% of
the total direct land and water use of the UMCG.
Note that currently 58% of all food assigned to the warm meals for the patients is discarded. This equals a
value of €0.6 million. Independently of the size of the environmental impact (expressed either in indirect
energy use, CO2 eq emission, land or water use), a reduction of 58% of the environmental impact is
possible. This is significant and should be addressed by the UMCG.
Part of this reduction is already addressed in March 2013, when the UMCG switches to a decoupled food
system. This change will probably reduce the amount of food-waste. Besides the change in the food
system, there are other possibilities to reduce the environmental impact from the food system. These
possibilities are the answer to the remaining three research questions. The remaining three research
questions are summarized by the main research question of this thesis is: “What are possibilities to reduce
the environmental impact from the current food system (focused on the warm meals to the patients) of the
UMCG?” To answer this question, multiple hot-spots are identified that could help the UMCG to reduce
their “foodprint”. These hot-spots are:
41

Policy measures
• Relatively easy and short term measures
o Food theme days
o Reduce meat consumption
• Complex and long term measures
o Donate left-over food to food banks
Technical measures
• Relatively easy and short term measures
o Reduce waste-costs
o Install separate meters at the kitchen
• Complex and long term measures
o Use environmental benchmarks
o Install a Pharma filter
These measures all have benefits either on the People (e.g. green image, healthy diet), Planet (benefits the
environment) or Profit-side (reduces the costs). All proposed measures do not ask for an additional
investment, except from the Pharma filter. Research by an employee of the UMCG showed that the
Pharma filter would have a return on investment of 10 years. This might drop in the future, due to
changing regulations for the discharge of wastewater.
All the described measures would fit well into the intensions that UMCG has for making Corporate Social
Responsibility a more important focus of the hospital.
42

8 DISCUSSION
At the start of this research, it was assumed the purchased food items might have a significant
contribution to the total CO2 footprint of the UMCG. One of the conclusions of this thesis is that this is
not the case: the food items only represent a contribution of 1% to the total CO2 footprint of the UMCG.
Can the discrepancy between the assumption made in advance and the conclusion be explained?
First of all it should be mentioned that the assumption was made based on household orientated literature.
The UMCG is a large hospital which has a completely other expenditure end energy use pattern than an
average household. This alone could already explain the discrepancy. But there are four additional
reasons that suggest that the indirect energy use and CO2 eq emission calculated in this thesis could be
higher or lower in reality.
The first reason is that all the ingredients used for the patient warm meals had to be selected by hand from
a total purchase list. It was not always clear which products were used for patients-only and which were
also used to prepare meals that are for the staff, visitors and students. So it is possible that the purchase
list used contains either too many or too few food items. All the items that were fresh (vegetables, meat,
and so on) were on a separate list. Here, a separation was possible. The fresh items have the largest
portion of the total, so this makes any effects of misclassification very small from an environmental
impact point of view.
Second, a more complete picture of the CO2eq emission of the food system in the hospital can be obtained
if all food items are included in the research. This does not only mean the other two (bread) meals for the
patients, all their drinks and diet supplements. Also all the other food consumed by staff, visitors and
students inside the hospital should be added to the analysis. This may increase the visibility from the
CO2eq emission of the food system in the whole CO2 footprint of the UMCG. So the research performed
for this thesis is only part of the total research that should be done in order to picture the complete CO2 eq
emission of the food system. Despite that, the methodology described in this thesis can easily be used for
expanding the research. So although further research would give a more complete picture, the foundation
for further research is provided by this thesis.
Third, the (indirect) energy use and the CO2eq emissions of transport for food and waste are not included
in this research. Both are also not included in the CO2 footprint analysis of the UMCG. This means that
the actual CO2 eq emission from the food system can only increase. But with what quantity and whether it
would make a significant change with respect to the total CO2 footprint is not known.
Fourth and last point of discussion is the level of detail in the CO2 eq emission analysis of the food
system. In order to perform a very detailed cradle-to-grave assessment for the environmental impact for
food items, more information is needed. For this thesis, the food items are gathered in larger food groups
which are assigned to one of the seven product categories. Assessing each product individually would
give a more complete (and correct) picture of the environmental impact. In this research he origin of the
products, the agricultural method and the transporting distance were not taken into account specifically.
Instead, averages were used per product group. Although this method is justified because of the limited
impact the foodstuffs have compared to the impact of the whole UMCG.
43

8.1 Research recommendations
The research done for this thesis sheds light on possible other subjects for research linked to the
environmental impact of the UMCG. One of the objectives for this study was a baseline analysis of the
UMCG food system, which can be used for comparison in later studies. This follow-up study could be
expanded with additional research in several ways, described below.
Study the bread meals served to the patients
These meals are prepared at the wards and all food-waste is discarded there. But as bread can be digested
efficiently, it could be interesting to add the food-waste of the bread meals to the swill tank. Because
bread clogs the swill tank, more water should be added. This would result in a further dilution of the swill
and maybe a higher frequency of emptying the swill tank. So a study into the possibility to add the foodwaste
from the wards to the swill tank might give interesting results.
Study the food-waste in more detail
This research worked with assumptions about quantity of food-waste and the location where this waste
arises. It is possible to perform a detailed study of the food-waste by weighting all food-streams in a
certain period (e.g. one week). This can be combined with a study on the incidence of malnourishment at
the UMCG, because one of the results of such a study is the quantity of food consumed by patients. This
study can be performed in great detail, using separate weightings of the different meal components. The
article published by Snels and Soethoudt gives a methodology for such a research, specifically applied to
a hospital (Snels and Soethoudt, 2012).
Next to the expansion of a follow-up study, there are other studies possible that shed a light on the
possibilities to reduce the entire environmental impact of the UMCG.
Complete the CO2 footprint
There are several items missing from the CO2 footprint of the UMCG. The items that could be added are
(but not limited to):
• A complete analysis of the food system, including all patient meals and the meals served to staff,
students and visitors.
• All purchased items (e.g. bandages, operation materials, etc.)
• The CO2 emission caused by transporting food, waste and other materials. (CO2 emission of the
vehicles owned by the UMCG are included)
Perform a waste sorting analysis
The waste sorting analysis will show how much biodegradable waste is disposed at certain places in the
hospital. A waste sorting analysis could also help estimating the added value of a Pharma filter. If a
Pharma filter is installed, all the waste will be discarded with the sewerage. The higher the fraction
biodegradable waste is, the more energy the digestion process will yield.
44

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46

Pretty J.N., Ball A.S., Lang T. and Morison J.I.L., 2005. Farm costs and food miles: An assessment of the
full cost of the UK weekly food basket. Food Policy, 30:1-19.
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Accessed:30-01-2013.
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Voedingscentrum, 2012. Webpage: www.voedingscentrum.nl. Accessed: 10-11-12.
47

Wartena, A., 2012. Personal communication with A. Wartena, head of the kitchen at the UMCG. Date:
November 2012 - January 2013
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http://2010.wereldvoedseldag.nl/downloads/brochure_minder_afval_minder_honger.pdf Accessed: 10-
10-2012
48

10 APPENDIX A – A BELT CART
Figure 12 - A belt chart (side used by staff to portion the meal)
49

11 APPENDIX B – THE AUTUMN MENU 2011
First week autumn
cycle code General Food Vegetarian food
Monday vla pork sausage lentil dish/ sultanas
day 1 vlb bovine meat
vle cheeseburger/meatball
10-Sep jsa gravy curry sauce
24-Sep jse curry sauce
8-Oct gra
22-Oct grb Brussels sprouts
5-Nov grc beetroot
19-Nov ara autumn mash
3-Dec nga vanilla custard
ngc peach compote
efa apple
efa fruit of the season
evrk tomato salad
Thursday spa couscous salad couscous salad
day 2 vla veal-curry ragout curry ragout
vlb chicken breast
11-Sep vle veg.nuggets / grillburger
25-Sep jsa
9-Oct jse
23-Oct gra iceberg lettuce/dressing
6-Nov grb chicory
20-Nov grc green beans
4-Dec ara white rice
nga tangerine custard
ngc pineapple compote
efa banana
efb grapes
evrk fennel/cheese salad
Wednessday vla cod fish kaassoufle
day 3 vlb beef meat
vle vegetable burger/fish sticks
12-Sep jsa ravigotte sauce
26-Sep jse bell pepper sauce
10-Oct gra Mexico mix
24-Oct grb carrots
7-Nov grc Romano beans
21-Nov ara Parisian potatoes
5-Dec nga semola pudding/ red berries
ngc stewed pears
efa apple
efb melon salad
evrk white cabbage salad
gaa mayonnaise
51

52
Thursday spa Italian salad Italian salad
day 4 vla Bolognese sauce (biological) Bolognese sauce (biological)
vlb turkey breast
13-Sep vle cheese croquette/ "frikandel"
27-Sep jsa
11-Oct jse
25-Oct gra daikon/carrot/pickle
8-Nov grb cauliflower
22-Nov grc garden peas
6-Dec ara spaghetti (biological)
nga vanilla yoghurt (biological)
ngc fruit cocktail
efa banana
efb orange
evrk zucchini salad
gaa parmesan cheese
Friday vla chili stew chili stew
day 5 vlb pork steak
vle tofu balls / grilburger
14-Sep jsa …
28-Sep jse
12-Oct gra garden peas
26-Oct grb steamed Chinese cabbage
9-Nov grc carrots
23-Nov ara parsley potatoes
7-Dec nga chocolate custard
ngc rhubarb compote
efa apple
eaf orange
evrk corn/bell pepper salad
Saturday vla salmon ragout corn and eggs ragout
day 6 vlb turkey minced meat
vle veg.chiliburger / fish sticks
15-Sep jsa
29-Sep jse
13-Oct gra broccoli
27-Oct grb Breton vegetable mix
10-Nov grc spinach
24-Nov ara penne
8-Dec nga custard with Dutch amaretti
ngc cherry compote
efa banana
efb fruit of the season
evrk cucumber salad

Sunday vla chicken Marrakech tahoe Marrakech
day 7 vlb beef meat
vle French stirred egg / meatball
16-Sep jsa
30-Sep jse mushroom sauce
14-Oct gra corn/ fruit salad
28-Oct grb red cabbage
11-Nov grc string beans
25-Nov ara couscous
9-Dec nga strawberry bavarois cherry custard
ngc compote of the day
efa apple
efb tangerine
evrk carrot/ apple salad
Second week autumn
cycle code general food vegetarian food
Monday vla steamed whiting bell pepper stuffed with risotto
day 8 vlb beef
vle quorn burger / chicken nugget
17-Sep jsa dill sauce ….
1-Oct jse pesto sauce
15-Oct gra carrots
29-Oct grb celery
12-Nov grc cauliflower
26-Nov ara baked potato
10-Dec nga caramel custard
ngc peach compote
eaf banana
efb fruit of the season
evrk white cabbage/tangerine salad
gaa mayonnaise
Tuesday spb tuna salad vegetable salad
day 9 vla …….
vlb chicken breast
18-Sep vle vegetable balls/ meatball
2-Oct jsa
16-Oct jse
30-Oct gra tomato olive salad
13-Nov grb euro mix
27-Nov grc Romano beans
11-Dec ara macaroni fantasy
nga vanilla yoghurt
ngc fruit cocktail
efa apple
efb grapes
53

54
gaa parmesan cheese
evrk iceberg lettuce/ dressing
Wednessday vla ajampangang quornpangang
day 10 vlb beef meatball
vegetarian loempia /
vle
"frikandel"
19-Sep jsa pangang sauce tomato sauce
3-Oct jse
17-Oct gra atjartjampoer
31-Oct grb endive
14-Nov grc beetroot
28-Nov ara mie fang goreng (egg noedles) mie fang goreng (egg noedles)
12-Dec nga rice pudding with cherries
ngc stewed pears
efa banana
efb tangerine
evrk cauliflower/ bell pepper salad
chicken/walnut/ pineapple
Thursday spa
salad celery salad
day 11 vla bacon steak (biological) vegetarian sausage
vlb chicken breast
20-Sep vle rice burger/ grill burger
4-Oct jsa gravy onion sauce
18-Oct jse ginger/pineapple sauce
1-Nov gra
15-Nov grb leek/cheese sauce
29-Nov grc haricots verts
mash with sauerkraut
13-Dec ara
(biological)
nga orange yoghurt (biological)
ngc pineapple compote
efa banana
efb fruit of the season
evrk beetroot/apple
Friday vla omelets, farmers style stirred egg
day 12 vlb pork schnitzel
vle mushroom burger /fish sticks
21-Sep jsa tomato sauce tomato sauce
5-Oct jse broccoli sauce
19-Oct gra queen mélange
2-Nov grb steamed green cabbage/ curry
16-Nov grc broccoli
30-Nov ara white rice
14-Dec nga strawberry custard
ngc rhubarb compote
efa apple
efb melon salad
evrk chicory salad / dressing

Saturday vla meat stew stew
day 13 vlb ham
vegetable croquette /
vle
"frikandel"
22-Sep jsa
6-Oct jse
20-Oct gra red cabbage
3-Nov grb green beans
17-Nov grc carrots
1-Dec ara mashed potato
15-Dec nga pudding of the day
ngc cherry compote
apple
efb pear
evrk cucumber salad
Sunday vla pork medallion steamed bell pepper/tomato
day 14 vlb minced beef
Javanese disk / chicken
vle
nuggets
23-Sep jsa cream sauce cream sauce
8-Oct jse
22-Oct gra broccoli
5-Nov grb Spanish salsify
19-Nov grc garden peas
2-Dec ara backed potatoes
16-Dec nga chocolate bavarois
ngc compote of the day
efa banana
efb fruit of the season
evrk daikon/carrot/cucumber
55

12 APPENDIX C – PRODUCT CATEGORIES AND PRODUCT GROUPS
2011 Purchase list Product group table A1 designation weight in CO2 eq
kg total
Product category
1. Bread, pastry and flour products
Flour Flour (paper bag) 1.1E+03 1.3E+03
Rice Rice (plastic bag) 7.1E+03 1.3E+04
Pasta (incl. mie) Pasta (plastic bag) 2.4E+03 2.9E+03
Potato starch Potato starch (cardboard box) 6.3E+02 8.9E+02
2. Potatoes, vegetables and fruit
Fruit (Dutch: apple, pear) apples (plastic bag) 4.9E+03 4.6E+03
Fruit (tropical) bananas 1.1E+04 1.4E+04
Fruit (canned) fruits in juice (can) 4.3E+03 1.0E+04
Vegetables other leaf vegetables (open air) 4.3E+04 3.0E+04
Tomato, salad and cucumber chicory and lettuce (greenhouse) 7.9E+03 3.3E+04
Potatoes Potatoes (plastic bag) 3.5E+04 6.0E+03
3. Beverage and products containing
sugar
4. Oils and fats
5. Meat, meat products and fish
Sugar, sugar syrup, sweeteners sugar (paper bag) 4.4E+03 6.9E+03
Honey honey (glass pot, plastic lid) 9.0E+01 2.7E+02
Fruit Juice orange juice (cardboard package) 1.2E+03 1.5E+03
Olive oil, frying oil, margarine vegetable oil 4.3E+03 1.1E+04
Pork pork (fresh, chops) 1.4E+04 1.1E+05
Beef beef (fresh, streaky) 2.2E+04 2.2E+05
Fish fresh fish (e.g. cod) 1.5E+04 1.1E+05
Lamb other sausages and meat products (package) 1.9E+02 1.7E+03
Poultry chicken filet (fresh) 9.9E+03 7.7E+04
57

6. Dairy products and eggs
7. Other products
58
Desserts
fruit yogurt (skimmed, liter, cardboard
package) 3.5E+04 3.7E+04
Cheese cheese (48+, ripe) 5.1E+02 3.6E+03
Cream cream (cardboard package) 6.7E+02 2.4E+03
Eggs eggs (cardboard box) 2.2E+02 4.9E+02
Salt, herbs, broth powder Median of Table A1 2.2E+04 3.8E+04
sauces sauces and relish (25% oil, plastic bottle) 1.9E+04 6.5E+04
Tinned tomato (concentrated) vegetables (can) 1.9E+03 2.1E+03
Other NES Median of Table A1 2.8E+03 4.9E+03
Composed meals (loempia, lasagna) main coarse dishes (cooled, plastic tray) [2] 2.7E+02 1.4E+03
Meat substitute 8.0E+02 4.1E+03

13 APPENDIX D – METHANE CALCULATIONS
Table 11 - Theoretical methane yield from the swill and grease produced at the UMCG in 2011 (Steffen et al., 1998,
Biowattsonline, 2013)
Swill Grease from grease trap
Total weight 182, 000 kg 100,000 kg
% dry weight (DW) 26% 36%
% volatile solids (VS) 90% 98%
Total volatile solids 42,915 kg 35,280 kg
Biogas yield per kg VS 0.48 m 3 0.35 m 3
% methane 75% 61%
Total methane 15450 m 3 7532 m 3
Total energy content 0.6 TJ 0.3 TJ
The total yield in methane is calculated as follows:
Weight x DW% x VS% = total volatile solids
Total VS x biogas yield in m 3 = Biogas yield
Biogas yield x % methane = m 3 methane
(M 3 methane x caloric value methane) /1000,000 = total energy content in TJ
The caloric value of methane: 35.88 MJ/m 3 (Agentschap NL, 2011)
59

14 EXECUTIVE SUMMARY BEHOREND BIJ:
The warm meal “foodprint” of the UMCG
Afstudeeronderzoek in opdracht van het UMCG
Onder begeleiding van Royal HaskoningDHV
Auteur: E. T. Politiek, maart 2013
Samenvatting
Voeding veroorzaakt een flinke belasting op het milieu. CO2 uitstoot, energie verbruik, water en land
gebruik zijn allemaal voorbeelden van die belasting. Voor elke calorie voedsel is een investering van
zeven calorieën nodig om dit voedsel uiteindelijk op tafel te krijgen. Ondanks de milieubelasting van
voedsel, gaat zo’n 30 tot 50% van het voedsel verloren of wordt het uiteindelijk weggegooid.
Met dit onderzoek is geprobeerd na te gaan wat de milieubelasting is van het voedingssysteem in het
UMCG. Om het overzicht te behouden is er voor gekozen om dit onderzoek te beperken tot de warme
maaltijd voor de patiënten. Met het oog op de verandering naar gekoppeld koken (in maart 2013) is dit
onderzoek een nulmeting van de huidige situatie. Er is voor dit onderzoek gewerkt met data uit 2011.
Wanneer het voedingssysteem in de toekomst opnieuw onderzocht wordt, kan het direct vergeleken
worden met de oude situatie. De milieubelasting wordt uitgedrukt in tonnen CO2 uitstoot. Op deze manier
is het in te passen in de CO2 footprint analyse die eerder al is gemaakt.
Figuur 1 - Alle voedselstromen (gerelateerd aan de warme maaltijd) naar, door en vanuit het UMCG in 2012
61

14.1 Conclusies
Figuur 1 is een visuele weergave van alle voedselstromen gerelateerd aan de warme maaltijd. Een deel
van het voedingsafval wordt niet in de swill tank gegooid, maar belandt bij het gewone ziekenhuisafval.
Het gaat dan om brood (maar dit is zeer gering ), fruit en voorverpakte etenswaren (fruithapjes, salades,
toetjes enz.). Het is opvallend is dat er naast de stroom swill (voedselresten) ook een stroom vet is uit
vetputten. Jaarlijks wordt er ongeveer 100 ton vet afgevoerd van het UMCG. Deze stroom staat niet
vermeld in het jaarverslag 2011, maar wordt net als de swill vergist om er energie mee op te wekken.
Zowel swill als vet zijn waardevolle reststromen. Zie ook de aanbevelingen hieronder.
In 2011 is er voor ongeveer € 0.6 miljoen aan voedingsproducten (voor de warme maaltijd) weggegooid.
Dit betreft ca 58% van de producten die ingekocht zijn voor de warme maaltijd. In figuur 2 is de
voedselverspilling per maaltijd weergegeven. Het grootste gedeelte van de voedselverspilling vindt plaats
na het portioneren en treedt op in de opslag (derving), na het koken, op de afdeling zelf en bij retour naar
de keuken. Ongeveer 80% van het voedingsafval gaat naar de swill tank. De overige ca 20% beland in
gewone ziekenhuisafval. Per patiënt wordt er ongeveer 1.2 kilogram ingekocht waarvan ca 650 gram
wordt weggegooid.
62
Figuur 2 - Verdeling voedsel en afval per warme maaltijd (totale hoeveelheid 1,15 kg)
De milieu-impact van het voedingssysteem uitgedrukt in CO2 uitstoot is amper zichtbaar op het totaal van
het UMCG in 2011. Voeding vertegenwoordigt slechts 1% van alle CO2 uitstoot van het UMCG. Toch is
het interessant om na te gaan van welke productgroepen deze uitstoot afkomstig is. Dit is te zien in
afbeelding 2, waarin links het gewicht van de productgroepen is afgebeeld en rechts de CO2 uitstoot van
dezelfde groepen. Vooral vlees leidt tot een grote milieudruk.

Figuur 3 - Productgroepen voor de warme maaltijd, verdeeld per gewicht (links) en per milieu-impact
14.2 Aanbevelingen
De aanbevelingen van dit onderzoek zijn verdeeld in beleidsmaatregelen en technische maatregelen. De
aanbevelingen beogen de duurzaamheid van het UMCG te versterken: met de maatregelen zijn
verbeteringen te behalen op het gebied van het milieu (planet), financiën (profit) of sociaal (people). De
aanbevelingen zijn samengevat in figuur 4.
Beleidsmaatregelen
Relatief eenvoudige en korte termijn maatregelen
• Voedsel themadagen
Organiseer themadagen waarop bijvoorbeeld lokale voedselproducten centraal staan. Lokale
producten komen uit de nabije omgeving (minder transport) en zijn vaak duurzaam geproduceerd.
Maak een koppeling met het onderzoeksthema ‘Healthy Aging’ waarbij voeding een belangrijke rol
kan spelen.
• Vleesconsumptie verminderen
De huidige portie vlees is aan de ruime kant vergeleken met de aanbeveling van het voedingscentrum.
Op verschillende manieren kan men de vleesconsumptie verminderen. Dat is vaak nog gezond ook.
Denk aan: een dagje geen vlees, een minder grote portie vlees of het stimuleren van twee keer vis per
week.
Complexe en lange termijn maatregelen
• Overgebleven voedsel doneren aan de voedselbank
Vooral na het portioneren is er veel voedsel over van prima kwaliteit. De verwachting is wel dat deze
stroom zal afnemen na het overgaan op ontkoppeld koken.
63

Technische maatregelen
Relatief eenvoudige en korte termijn maatregelen
• Afvalkosten verminderen
Zowel met swill (keukenafval) als met vet kan men energie opwekken. Het zijn dus kostbare
reststromen. Bij de nieuwe aanbesteding van contracten voor de afvalverwerking verdient het
daarom aanbeveling om dit gegeven te betrekken bij de onderhandelingen.
• Meters installeren in de keuken
Er is nu weinig inzicht in het energie en water verbruik in de keuken. Dit valt eenvoudig op te
lossen door extra meters te plaatsen, dit zou ook een digitale meter kunnen zijn (bijvoorbeeld
Plugwise). Met de extra metergegevens kan men realistische, plaatsgebonden besparingsdoelen
formuleren.
Complexe en lange termijn maatregelen
• Gebruik maken van milieu benchmarks
Alle ziekenhuizen in Nederland rapporteren nu nog op hun eigen wijze over hun milieuprestaties.
Om deze te kunnen vergelijken, zou het praktisch zijn als dit wordt gelijkgetrokken. Er bestaan al
enkele milieu benchmarks, zoals de ‘Milieuthermometer Zorg’ van het Milieuplatform Zorg.
• Een Pharmafilter in gebruik nemen
Recent onderzoek toonde aan dat een Pharmafilter bij het UMCG niet tot CO2 of energiereductie
zou leiden. Wel zouden allerlei medicijnresten uit het geloosde afvalwater kunnen worden
gezuiverd. Hoewel een Pharmafilter nu (financieel) nog niet uit kan, is het verstandig om de optie
voor de toekomst open te houden. Zeker op het gebied van afvalwater wordt verwacht dat de
wetgeving strenger zal worden in de toekomst. De terugverdientijd van een Pharmafilter zal
daardoor omlaag gaan.
64
Figuur 4 - Samenvatting van alle aanbevelingen