Are sustainable and healthy diets always compatible? Needs for an emic-oriented cultural research on sustainable consumption

By Fumiko Kano Glückstad

◦ 6 min read 

It is widely acknowledged that a plant-based diet is healthier than an animal-based diet (Willett, et al. 2019). However, a group of Japanese researchers recently published a thought-provoking article demonstrating that a lower diet-related Greenhouse gas emission (GHGE) has generally resulted in an inadequate nutrient intake among Japanese adults (Sugimoto et al. 2020).

Their results seem to support the fact that the Japanese Government has excluded any dietary-related initiatives from its long-term national strategies concerning the targeted 80% reduction of greenhouse gas emissions by 2050. In other words, Japanese opinion leaders seem to challenge the generally accepted viewpoint of a direct positive correlation between a sustainable diet and a healthy diet, contradicting widely accepted European studies and initiatives (e.g. Sjörs et al. 2017). This apparent controversial observation motivated me to look into the historical development of meat consumption on a global scale. Most importantly, the recently published guiding principles by the Food and Agriculture Organization of the United Nations (FAO) and World Health Organization (WHO) in 2019 state that “Sustainable Healthy Diets” are a trade-off between the two dimensions: sustainability and healthiness of diets. Thus, countries should decide on such trade-offs in consideration with their situation and goals (FAO & WHO, 2019). 

The following figure indicates such a trade-off situation for various geographical regions and it clearly shows that the meat consumption in Western countries is obviously higher than the rest of the world such as compared to e.g., Africa or Asia, although a substantial increase of meat consumption is observed in both China and Japan.

In particular, the main increases observed in China and Japan seem to be well-synchronized with the periods of their respective economic developments that simultaneously triggered their modernization (Westernization) process in their markets. However, the curves of Japanese and Chinese meat consumption also show a noticeable difference. Whereas the meat consumption in China has steeply increased since the 1980es, Japan seems to moderate its increase from the early 1990es and ahead, which is most likely explained by their respective economic developments. However, in this blog, I want to supplement these observations with some personal insights on what has happened in Japan during this period through my work experiences in the related industry.

Meat consumption in this blog refers to the average supply of meat across the population shown in this figure. Food supply is defined as food accessible for human consumption meaning the food remaining for human use after deduction of all non-food utilizations. Source: Our World in Data

During the Japanese bubble economy in the 1980es to the early 1990es, the Japanese middle class had increasingly wider opportunities to be exposed to the Western food culture due to their Westernization. This somewhat alarmed key Japanese health professionals, nutritionists, food experts and industries who considered a ”Western lifestyle and food culture” as a source of lifestyle-related chronic diseases e.g., diabetes 2 and cardiovascular issues, which would gradually impact Japanese consumers.

This subsequently triggered a countless number of initiatives aimed to nudge a wide range of the population towards a healthier diet. The initiatives were eventually formalized as a Health Promotion Act in 2002 and the Basic Law on “Shokuiku (food and nutrition education)” in 2005 by the Japanese government (MAFF, 2019).

Source: Ministry of Agriculture Forestry and Fisheries. 2019. “A Guide to Shokuiku.”

The Shokuiku act has since become a comprehensive program targeting everyone from school children to the elderly, and its initiatives have involved a broad range of Japanese stakeholders, not only the central and local governments, health professionals and nutritionists but also food and restaurant businesses and their consumers.

The Shokuiku program has promoted the nutritional education from a holistic viewpoint and emphasized the importance of enjoying healthy meals from societal and cultural perspectives through various sensory food experiences. As a consumer researcher in the 1990es in one of Japan’s largest high-tech companies producing various kitchen appliances, I also personally participated in a variety of initiatives involving consumer organizations, health professionals, nutritionists and food and restaurant businesses to nudge consumers towards a healthy diet at that time. 

In a European context, nudging consumers towards a sustainable and healthy diet usually implies the replacement of an animal-based diet with a plant-based diet with emphasis on ingredients. One major difference to the Japanese nudging initiatives is that the Shokuiku promotion has encouraged consumers to learn how to select “nutritionally balanced meals” in their daily life while enjoying variations in sensory food experiences. Consumers have many ways to achieve this by following the “Japanese food guide spinning top” that can be easily followed by a wide range of population groups, i.e. from school children to the elderly (see the below picture). The maintenance of a moderate meat consumption level observed from the Japanese curve in the above figure might be partially attributed to such ‘enjoyable’ Shokuiku initiatives (see Yoneda, 2019).

Japan has been able to moderate its overall meat consumption without specific promotions of plant-based diets also thanks to the traditional Japanese food culture that is originally rooted in a plant-rich diet. Thus, in a Japanese context, it is perceived possible to achieve a well-balanced diet while simultaneously enjoying variations in sensory food experiences, in other words, nudging a healthy diet can be perceived as an enjoyable experience. Interestingly, Kanemoto et al. (2019) recently reported that meat consumption only weakly explains the difference between high- and low food carbon footprints (FCF) among 60,000 Japanese households. This study ponders that Japanese should (also) consider restricting their consumption in other areas than meat consumption with a higher estimated FCF such as restaurant foods, confectionary and alcohol. 

Source: Ministry of Agriculture Forestry and Fisheries. 2019. “A Guide to Shokuiku.”

These observed trends indicate the importance of fully understanding social, cultural and dietary contexts in various countries and regions when researching on sustainable food consumption because food is inherently deeply rooted in the specific cultures. In other words, sustainable consumption studies should ideally shed more light on an emic approach addressing a specific sample of that region and discuss adaptability of such studies to countries outside of the specific region with due respect of the embedded cultural contexts. 

About the Author:

Fumiko Kano Glückstad is Associate Professor of Cross-Cultural Cognition at the Copenhagen Business School. She works in the area of cross-cultural psychology and her recent project “iBeauty” funded by the third largest Japanese cosmetic company investigates associations between personal values, beauty and well-being in cross-cultural contexts. She previously worked as a consumer researcher and product concept designer of kitchen appliances at Panasonic Corporation, one of the largest Japanese electronics industry enterprises.

Impact of COVID-19 on mortality inequalities: The case of France

By Clément Brébion

◦ 3 min read 

Despite an unprecedented worldwide decline in mortality over the last century, a substantial income gradient in life expectancy persists within most countries. In the US for instance, the 1% richest men have a life expectancy at the age of 40 that is 15 years larger than the poorest 1% (difference of 10 years for women) and this spread is currently increasing. In France (on which this blog post is based), the income gradient is of a similar size despite a more egalitarian access to health care.

Pandemics likely amplify this spread because they reveal latent inequalities in individual health capital and because they spread differently across living environments. Our recent study reveals that the COVID-19 crisis, which epitomizes such massive mortality shock on a worldwide scale, is not an outlier in this respect.

A few definitions

We analyse the impact of COVID-19 on mortality inequalities over the whole year 2020 in France, one of the most severely hit country in the world. We use comprehensive registered data, allowing us to study the evolution of mortality as well as the income level of each municipality of metropolitan France. Given the unreliability of public data on deaths attributed to COVID, we focus on excess mortality occurring in each municipality, defined as the deviation in 2020 all-cause mortality with respect to the average of 2019 and 2018. The link between poverty and morality related to the epidemic is thus analysed by comparing excess mortality between ‘rich’ and ‘poor’ municipalities, where ‘poor’ is defined as belonging to the poorest 25% of municipalities (‘Q1’ hereafter).

Two waves that have affected more the poor municipalities 

Figure 1 below shows that, as in many European countries in 2020, France has been hit by two distinct waves that peaked in April (17,000 extra-deaths) and November (15,100 deaths), respectively. Each time, a lockdown was implemented at the national level to reduce the spread of the disease (March, 17 to May, 11 & October 30 to December 15). The first lockdown was the most stringent and has seemingly worked best to reduce casualties to COVID-19.

Figure 1: The figure represents the difference between the monthly number of deaths in 2020 and its average over 2019 and 2018 in France

Figure 2 shows the distribution of excess mortality across municipalities according to their income. Each month, the figure shows the average number of abnormal deaths that occurred since the beginning of the year in each group of municipalities (per 10k. inhabitants). While no specific pattern can be seen over the first three months of 2020, a marked difference between the two groups of municipalities appears in April (wave 1), that further grows as the second wave takes place (October-December). 

In-depth analyses tell us that excess mortality in poor municipalities was 30% larger than in non-poor municipalities in 2020 (2.6 more extra-deaths per 10k. inhabitants). Our research shows that this spread directly relates to COVID-19 and is not explained by differences in the geographical localisation, in the share of old-age inhabitants or in the life conditions under the lockdown between rich and poor municipalities.

Figure 2: The graph plots the cumulative sum of all excess deaths per 10,000 inhabitants from January 2020 for poor and non-poor municipalities in French urban areas.

The fact that the income gradient uncovered during the first wave is not compensated during the second wave, but rather reappears with regularity every time the epidemic returns must be emphasized. One can indeed show that the income gradient is the strongest in areas that got most affected by COVID-19 in 2020. If further epidemic waves occurred – and some signs suggest that it has already started in France as well as in several other countries – our result suggest that, once again, the poorest municipalities will suffer greater losses.

Worse housing conditions and higher exposure through employment

What are the main differences between poor and non-poor municipalities that explain the income gradient in Covid-19 mortality? Our analysis highlights the key mediating role of labour market and housing conditions, in line with the idea that local factors are important determinants of the spread of epidemics. More specifically, the larger share of essential workers and of overcrowding housing almost fully explain the income gradient in COVID-19 related mortality. Interestingly, labor-market exposure remains an important determinant of COVID-19 mortality across both waves, while the role of housing conditions decreases over time, probably because the second lockdown was less stringent. 

Our work shows that the current health crisis amplifies already existing socio-economic inequalities. It also suggests that public policies aiming at limiting its effects should primarily focus on the poorest municipalities, notably by protecting workers as much as possible in the short term and by improving housing conditions in the medium term.


Brandily, P., Brébion, C., Briole, S., & Khoury, L. (2021). “A Poorly Understood Disease? The Impact of COVID-19 on the Income Gradient in Mortality over the Course of the Pandemic” , Working Paper, n° 2020-44, Paris School of Economics.

About the Author

Clément Brébion joined CBS in September 2020 as a postdoctoral researcher.  He received his PhD in economics in November 2019 from the Paris School of Economics. His main research interests are labour economics, economics of education and industrial relations. He has a particular interest into comparative research. More recently, he started working on the EU H2020 project HECAT that aims at developing and piloting an ethical algorithm and platform for use by PES and jobseekers.

Can we pay for success in healthcare?

By Mikkel Munksgaard

Demographic megatrends, such as ageing populations, challenges public health budgets in developed countries. Currently, health costs in OECD countries are growing at roughly double the rate as the average growth in GPD. ‘Pay for Success’ is an emergent, and highly innovative, partnership model promising both increased cost-effectiveness and patient-centric services in healthcare. Whether or not the model will constitute a critical feature of future health systems, only time will tell. 

Due to critical leaps in modern healthcare and medicine, the average life expectancy in developed countries has doubled since 1900 [1]. While this is an important success, it also challenges public health systems because chronic diseases occur much more often at old age. In fact, a Danish report states that the average health costs for an 86-year-old are 16 times higher than for a 20-year-old [2].

In addition, public health sectors are experiencing structural challenges inhibiting their capacity to deliver services effectively.

The lack of systematic assessments towards quality and outcomes of services creates disproportionality on financial priorities. Evidence indicates that up to 30% of healthcare expenses are wasted on unproven or unnecessary treatments.

World Economic Forum 2017

An example of this is the general de-prioritization of preventive health interventions over short-term illness treatment. 

Introducing ‘Pay for Success’ 

‘Pay for Success’ (PFS) has emerged as an organizational solution to the problems of asymmetry and ineffectiveness in public health.  A PFS-program is fundamentally a public commissioning model based on two distinctive features 1) an outcome-based contract and 2) the engagement of an external ‘investor’.

In an outcome-based contract service delivery is outsourced to a provider and the public commissioner pays for the realization of long-term health outcomes. Hence, the public “pays for success”. Because services, such as preventive interventions, could take several years to deliver the PFS-model involves an ‘investor’ that provides working capital for the provider – and thus, takes the majority of the financial risk. This could either be a non-profit organization, a for-profit organization, or both.  The first PFS-program was developed in 2010 and since then 200 programs have been initiated mobilizing a total capital of 420 Million Dollar [3]. Especially in the UK, the PFS-market has grown and is predicted to soon reach a total value of 1 Billion Euro (Carter 2019).

A simplification of the PFS-model inspired by Third Sector (2016) 
Challenges and future directions of ‘Pay for Success’ 

While empirical studies from the UK and US does indicate that the PFS-model performs better than other commissioning models [4], they also highlight a more complex organizational structure that takes time and resources to develop – which, consequently, creates high transaction costs ultimately challenging the model’s cost-effectiveness. Technical problems related to valuating health outcomes, and creating a payment structure around such, has proven difficult and time-consuming. Additionally, the complex governance structure of PFS-programs in the UK and US has been criticized for being too rigid and focused on short-term performance – thus, inhibiting innovation. 

The emergence of PFS-programs in Scandinavian countries poses an interesting field as emerging research indicates that these programs are fundamentally different from traditional PFS-models. The tendency to utilize more networked practices as well as the existence of comprehensive public data systems in Scandinavian welfare states could potentially solve some of the most critical challenges currently faced in PFS-development. What would seem critical for future PFS-development is to leverage these emerging insights and shine more light into the ‘black box’ of PFS-development.


[1] World Economic Forum 2017

[2] Kjellberg and Højgaard 2017

[3] The Brookings Institution 2021

[4] Albertson et al. 2018

About the Author

Mikkel Munksgaard Andersen is Ph.D. Fellow at CBS, MSC. Through his Ph.D.-project, Mikkel studies the development and implementation of social impact bonds and payment-by-results methods in Denmark. His work centralizes around the distinct characteristics of Scandinavian impact bonds and their role in supporting and financing public services. The research takes a point of departure in the Danish research- and innovation project PreCare which seeks to develop new services and organizational models for preventive and digitalized healthcare.  See more here.