The unbroken global refrigerated supply chain, or cold chain, is rapidly expanding in developing countries. In addition to increasing the energy intensity of the food system, the expanded cold chain may facilitate changes in the global diet, food waste patterns, food production and distribution, and shopping habits. The sustainability impacts of many of these changes chain are unknown, given the complexity of interacting social, economic, and technical factors. The current literature surrounding the environmental impacts of refrigeration in the food system focuses on the direct impacts of energy use and coolant emissions, and lacks a critical evaluation of the accompanying systemic societal changes that potentially carry greater environmental impacts. This review examines the cold chain as a transformative technology, identifying key intrinsic, indirect, and external factors that will favorably, unfavorably, or ambiguously impact the environmental profile of the food system. The review identifies key interactions and feedbacks between the cold chain, food production and consumption decisions, infrastructure development, and the global environment which are largely unexamined and in need of empirical data. Viewing cold chain expansion from this broader perspective is essential to understanding the changing impacts of the food system in developing countries and may inform future sustainability planning.