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Renal health benefits of sustainable diets in Japan: a review
Renal Replacement Therapy volume 8, Article number: 25 (2022)
Global warming may reduce food production and force people to adopt dietary habits of inadequate quantity or quality. Such dietary habits could trigger chronic kidney disease through inappropriate nutrition or lifestyle diseases. Livestock farming and other types of food production are responsible for many greenhouse gases. These problems are being emphasized as a diet-environment-health trilemma to be addressed on a global scale, with various methods being proposed toward its resolution. Diets like plant-based and low-protein diets not only potentially prevent the progression of chronic kidney disease, but are also rational from an environmental preservation perspective. Evidence from Japan on resolutions for this trilemma is sparse, but one concrete proposal is the use of traditional Japanese diets like washoku, the Okinawa diet, and the traditional Buddhist diet. However, traditional Japanese diets also have several problems, such as excessive salt content and caloric deficiencies, and need to be modified and incorporated into the current lifestyle. The progression of chronic kidney disease needs to be prevented with appropriate dietary treatment and environmental friendly manner.
The number of individuals with chronic kidney disease (CKD) is steadily increasing worldwide [1,2,3]. As a human economic activity, medical practice consumes various resources and impacts the environment and is estimated to account for 3–10% of all economic activity [4,5,6,7,8]. With the progression of CKD, increases are seen in medical expenses for medication, visits to doctors, and hospitalization , naturally resulting in greater greenhouse gas emissions (GHGE). In particular, dialysis treatment that is essential for prolonging the life of individuals with end-stage kidney disease uses vast amounts of electricity, water, and plastics and is estimated to have about ten times the environmental impact of the average per-person medical activities . The burden on the global environment, primarily from GHGE, further exacerbates global warming and produces various health problems, such as cardiovascular complications, respiratory disease, and mental disorders [11, 12]. Global warming may result in the onset or progression of CKD through a variety of mechanisms . As a direct cause, repeated acute kidney injury due to heat stress may result in chronicity of renal impairment, or trigger rhabdomyolysis or urolithiasis involve in development of CKD. Possible indirect causes are dehydration due to water shortages, tubular damage from contamination by nephrotoxic pesticides, insecticides, or heavy metals, and vector-borne illnesses such as malaria and dengue fever . Combined with typical causes of CKD, such as chronic glomerulonephritis, hypertension and diabetes, global warming has been suggested to potentially lead to an increase in the prevalence of CKD.
According to a Japan-wide statistical survey conducted at the end of 2019, diabetes and hypertensive nephropathy (nephrosclerosis) were the top one and two most common primary diseases, respectively, for newly starting dialysis therapy . Chronic glomerulonephritis was previously the most common and is not a lifestyle disease, and moved to third most common . This indicates a change in disease structure among renal diseases, such as an increase in lifestyle-related diseases. This is consistent with the current situation that in recent years, food habits around the world have been becoming more westernized , resulting in increased intake of animal protein as well as cardiovascular complications [17, 18]. Empirically, limiting salt and protein intake has been shown to help prevent the onset of uremia . While randomized controlled trials (RCTs) on educational interventions such as diet management and nutritional counseling are relatively difficult to conduct, limiting the possibility of accumulating high-quality evidence, experience leaves little doubt that nutritional counseling is an important part of CKD treatment.
If there is indeed an effect of global warming from the increase in GHGE caused by CKD treatment, as suggested above, food supply problems could result due to issues such as smaller crop yield, declining livestock production, and declining fish catch rates. However, most of current studies have not been able to directly quantify how much climate change will affect food yields, because it was forecasted by various uncertain anthropogenic factors . Environmental issues stemming from medical practices are therefore linked to diet and nutritional problems, as well as renal health problems, with interactions among the three types of problems likely. This diet-environment-health trilemma  should be addressed at the global level (Fig. 1). From a nephrology perspective, the environmental impact of dialysis treatment plays a strong role in this trilemma. Japan is the 5th highest producer of GHGE in the world  and has 344,000 patients on maintenance dialysis  and so has a great responsibility to combat the problem. In this review, we discuss how to achieve nutritional treatment that effectively prevents the onset and progression of CKD and a diet with less environmental impact in Japan.
Diet-environment axis: temporal changes in Japanese diets and GHGE
Dining tables in modern Japan are covered with foods made using various ingredients and methods. Ingredients can be broadly categorized as animal- or plant-based, with the former considered to produce far higher GHGE [20, 22,23,24]. Cows, sheep, and other ruminant species produce methane (CH4) and release particularly high GHGE [20, 22]. The food industry accounts for a high ratio of GHGE, so choosing a plant-based diet is a plausible way to improve the global environment [24, 25]. While the traditional Japanese diet (washoku) is plant-based and less processed food , intake of animal-based foods has increased from 114.9 g/day in 1955 to 338.7 g/day in 2019 and the processed food consumption ratio was 43.0% in 1990 and 50.5% in 2010, predicted to increase to 58.9% in 2035 . This diversification of diets in modern Japan, and especially the westernization of diet and overconsumption of processed foods, is expected to have impacts on both health and the environment. Furthermore, in addition to food production activities such as crop and livestock farming, Japan’s unique situation as a country with a low food self-sufficiency rate must be considered. Life cycle assessment (LCA) is a method for calculating various human economic activities (Fig. 2) [23, 24, 28]. For example, following a diet requires producing ingredients, transporting those ingredients, processing them into food products, and preparing them for meals. This entire process has environmental impacts, most notably from GHGE. The GHGE from importing and domestic transport processes cannot be overlooked [23, 29]. For this reason, evidence on LCA from other countries does not fit Japan as is, and making calculations and resolutions based on the specific characteristics of Japan, including diet, is important. In LCA research comparing modern Japanese-style, Chinese-style, and Western-style cuisines in Japan, ingredient procurement and preparation calculations have shown that Japanese-style meals have the lowest GHGE, although the differences are not dramatic (Table 1) . This may be partially attributable to the use of many imported products and processed foods in modernized Japanese foods. Traditional Japanese diets are shown in Table 2. Unfortunately, no LCA studies on these traditional diets have been conducted. Japanese-style cuisine (washoku) is high in fish and soybean consumption and low in animal fat and meat consumption. In Okinawa, which used to have the longest lifespan, people ate a sweet potato-heavy diet with small amounts of pork (a monogastric animal) that likely had low GHGE. In Japan and other countries in Asia where Mahayana Buddhism spread, a certain proportion of the population was vegan and people followed a traditional Buddhist diet that likely produced very low GHGE . However, as shown in the data for a strict traditional Buddhist diet in Table 2, energy and nutrients are supplemented as needed. Based on the above, when considering how to reduce GHGE, using washoku with domestically produced plant-based ingredients and incorporating a traditional Japanese diet may make rational sense from an LCA perspective.
Adapted and modified from Toshie Tsuda et al. Life cycle CO2 assessment associated with model menu in Japanese household. Journal of Life Cycle Assessment Japan. 2007;3(3):157–67  with permission. Abbreviations: GHGE, greenhouse gas emissions.
Diet-health axis: role of diets in chronic kidney disease
The importance of dietary treatment in renal disease has long been debated . A low-salt diet not only can help prevent the onset or exacerbation of hypertension and the onset of cardiovascular complications, but also may mitigate renal dysfunction and reduce urinary protein . Excessive protein intake leads to uremic symptoms, and a protein-restricted diet is believed to have preventive effect on CKD . Though it has been still clinically controversial that low-protein diets prevent or attenuate the progression of CKD, a general population-based observational study demonstrated people who consumed more protein from red and processed meats were at an increased risk of developing CKD  and end-stage kidney disease . On the other hand, CKD risk was significantly lower among those who had a higher consumption of nuts and legumes suggesting plant protein offers advantages over animal protein in patients with CKD . In the case of mild CKD, active intake of potassium can help prevent the development of cardiovascular complications and hypertension [37, 38]. Examples of typical diets for implementing such dietary treatment are traditional diets such as the Mediterranean diet and the Okinawa diet  and diets based on clinical research and/or academic society recommendations, such as the Dietary Approaches to Stop Hypertension  or a protein-restricted diet . Common points for all these diets are the plant-based nature with low salt and protein contents, and high potassium content. A search of the literature regarding the relationship between progression of CKD and nutritional education interventions gives 494 hits, including 22 RCTs. As expected, most interventions involved restriction of protein or salt, but evidence on the Mediterranean diet was also included [41,42,43] (Fig. 3). Among all races, the Japanese, both men and women, have long life expectancies, and evidence suggests that traditional Japanese diets can prolong life and reduce the risks of cardiovascular complications [44, 45]. However, scientific evidence is currently lacking on progression of CKD as an outcome of intervention with a traditional Japanese diet (Fig. 3). Conversely, as increased potassium intake in advanced renal disease can carry a risk of cardiac death from hyperkalemia, nutritional treatment requires considerations by specialists. In recent years, CKD patients have become older, so careful nutritional guidance is also required. For older adults, excessive salt or protein restriction can lead to frailty and may aggravate prognosis.
To summarize, while a number of issues require caution, plant-based diets generally offer clear benefits in preventing the onset and progression of CKD . Although following a vegan diet is difficult in modern Japan, increasing the proportion of plant-based foods in a diet is possible with nutritional counseling. Moreover, traditional Japanese diets also have several problems, which are listed as caloric deficiencies, excessive salt content (Table 2) and reduced satisfaction and quality of life due to unfitting modern society. Therefore, the traditional diets may need to be modified into diets balancing environmental sustainability and renal health based on recent nutritional science in CKD. However, the effects of a traditional Japanese diet on CKD have not been tested, and epidemiological and clinical evidence is needed.
Environment-health axis: life cycle impact assessment for better understanding of environmental issues by health care providers
Of the axes in the trilemma, we discussed the effects of diet on health in the previous section. In contrast, it is more difficult for medical professionals to understand the effects of the environment on health. The GHGE often used to assess environmental impact do not directly affect humans and are therefore called a midpoint indicator. Medical professionals have very few opportunities to imagine the effects of GHGE on the patients they are seeing in daily practice. On the other hand, end point environmental indicators in LCA include “monetary cost” and “health” that affect people . These are areas of interest in medical economics and public health science and can be easily understood by medical professionals. As LCA research has progressed in recent years, various methods of assessment have been established, such as Life cycle Impact assessment Method based on End point modeling (LIME), which can assess damage to health and economic impact . Carbon footprint research into dialysis for end-stage kidney disease has been ongoing since around 2010 and has shown the production of massive amounts of GHGE due to the use of a vast quantity of resources, including drugs, electricity, water, and plastics [10, 48,49,50]. We recently used LIME to measure the monetary loss and health damage of resource consumption with a dialysis treatment model as an end point environmental indicator that surpasses midpoint indicators . Considering a treatment model in which one patient on maintenance hemodialysis visits the hospital three times a week for 4 h of a dialysis session, we calculated a health damage of 2.4 × 10−3 disability-adjusted life years and environmental load equivalent to the monetary loss of 85.6 USD per year. Based on this result, 1 year of treatment for 418 patients on maintenance hemodialysis was equivalent to the loss of 1 year of healthy life for 1 person on earth. Importantly, this result ignores the health gained by the person on dialysis and therefore we never intend to deny dialysis treatment itself. The basic data used in the calculations were data used in other industries and agriculture, and the results are merely theoretical figures under a treatment model, and not actual measurements. The result may therefore be an under- or overestimation. That said, this is the first example showing that consumption of vast resources in medical practice damages human health.
Co-benefits of Japanese traditional diets on environment preservation and renal health
Resolving the diet-environment-health trilemma posed for renal health care requires the procurement and preparation of ingredients with a low environmental impact, nutritional treatments that effectively protect renal function, and wide acceptance of both in Japan as the dietary culture. In addition, reducing the number of people with CKD and the number of people on maintenance dialysis requires modification of patients, health care professionals, and the society that supports them. One useful method may be to scientifically determine what would be most effective for achieving both environmental and health benefits using quantitative LCA results [22, 23, 52,53,54]. We are currently speculating on whether a plant-based diet centered around domestically produced ingredients can improve both GHGE and CKD in Japan. However, it needs the environmental impact of domestic production must not exceed that of imports. To examine the possibilities, further development of LCA-based calculation methods is necessary.
Some specific plant-based diets are the traditional washoku diet, the Okinawa diet, and the traditional Buddhist diet. Using domestically produced foods reduces the need for transport, preserves links to ancient life history and culture, and may boost agriculture and the food industry in Japan. The low food self-sufficiency rate in Japan is related to the high cost of domestically produced food and policy issues related to trade. Unfortunately, for us, it has not been possible to estimate that food self-sufficiency in Japan would reliably reduce the environmental burden. Even though maintaining domestic food production may be more expensive than imported agricultural products in the short term, the long-term cost of maintaining domestic production is actually lower when the cost of the contingency of “not being able to buy food with your money” should be also taken into account. On the negative side, inadequate nutritional controls can cause frailty in older adults due to low protein intake or may trigger hyperkalemia in people with end-stage kidney disease. Furthermore, excessive salt content of traditional Japanese diet and lack of energy in traditional Buddhist diet are not acceptable levels. Nevertheless, if some issues and problems can be overcome and modified as “sustainable diets in Japan,” traditional Japanese diets may reduce both the carbon footprint and the prevalence of lifestyle-related diseases as midpoints. In advance of this, our team had started promotion of Japanese diets in new era, that is summarized by reducing the amount of salt by using dashi (Japanese soup stock). The achievement was released by the International Society of Renal Nutrition and Metabolism . Conceivable end points are protection of biodiversity, improvements in land use with structural changes to agriculture, suppression of increases in the prevalence of end-stage kidney disease, reductions in medical costs, and improvements in both the global environment and human health (Fig. 4).
Table 3 summarizes the relationship between diet and environment, between diet and renal health, and between the environment that is far removed from medical professionals and renal health. We consider resolving this trilemma for renal health could possibly improve the prognosis for people with CKD. Hopefully, this debate about renal health will have ripple effects on other medical fields and bring us closer to resolving the diet-environment-health trilemma in Japan.
As global warming progresses, renal health sector, without exception from other industries, will require effort to reduce GHGE. Doctors, other health care specialists must work together to try to prevent the progression of CKD for reducing the need of resource-hungry therapy for end-stage kidney disease. Traditional Japanese diets may offer a rational solution to the diet-environment-health trilemma. However, traditional Japanese diets also have several problems, such as excessive salt content, and need to be modified and incorporated into the current lifestyle as sustainable diets in Japan.
Availability of data and materials
Chronic kidney disease
Greenhouse gas emission
Randomized control trial
Life cycle assessment
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We would like to thank Rieko Uchima for helping us to determine the contents of the traditional Okinawa diet as a nutrition specialist.
This article was supported, in part, by Japan Society for the Promotion of Science Grant Nos. 18KK0431 and 19K17729 and by the Japanese Association of Dialysis Physicians Grant No. 2019-1.
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Nagai, K., Kosaka, S., Kawate, Y. et al. Renal health benefits of sustainable diets in Japan: a review. Ren Replace Ther 8, 25 (2022). https://doi.org/10.1186/s41100-022-00415-6
- Chronic kidney disease
- Life cycle assessment