Obesity — A Wicked Problem in Pittsburgh

Team Synergy: Silvana Juri, Eustina Daniluk, Isha Hans, Catherine Yochum

I. Background: understanding today’s snapshot of the problem

Beginning in the 1990s, the World Health Organization has led the charge in declaring obesity an epidemic at global scale. Worldwide the rate of obesity has been steadily climbing to a current prevalence of approximately two billion or roughly 30 percent. Obesity is also prevalent on a local scale. In the United State 39.8% of adults are obese, and according to 2017 figures, 35.6% percent of adults in the Pittsburgh region are obese.

Weight categories are screened using a measurement system called Body Mass Index (BMI).

BMI is determined by dividing the person’s weight in kilograms by the square of their height in meters. It is most useful for population assessment, but also strongly correlates with various metabolic and disease outcomes. In the BMI scale a person is considered overweight when their BMI falls between 25.0 and 29.9, while obesity is defined for a BMI of 30 or higher.

Obesity is a wicked problem because it is complex and involves a multitude of conflicting stakeholders, lifestyle choices, and physiological factors. One of the biggest obstacles to combating obesity is our evolutionary need to eat and the effectiveness of storing fat as a survival mechanism. Humans evolved to enjoy eating, worldwide cultural norms include food as a form of celebration and community. In addition, our biological predisposition to crave foods that are high in fat and sugar was an asset when food was scarce. However, in many societies food is more prevalent than anytime in history. This means all that excess fat just keeps accumulating…

Large companies working in the food sector have exploited our biological desire to eat by engineering foods that are more palpable and easier to eat quickly than foods found plentifully in nature. Furthermore, unhealthy, highly processed foods are cheap. Those living in lower socio-economic groups have a higher rate of obesity. Inequity and the social determinants of health are key drivers of unhealthy weight and diet-related non-communicable diseases.

Further exacerbating the difficulty of combating obesity, social norms in many cultures assign moral values on health and weight. Additionally, in Western media narratives around beauty and health are often framed around thinness (Julier 2012). These leaves many obese people to feel as if obesity is a moral issue to combat with willpower, rather than a complex medical issue.

If an obese person wishes to lose weight they are often confronted with confusing or contradictory information about what constitutes a “healthy” diet. Conducting long term studies on weight are difficult to conduct long term because they must rely on self-reporting. In addition, nutritional guidelines are regulated by national governments which can be influenced by lobbying, which suggest regulations undergo complex processes of negotiations between health and nutrition specialists, politicians and representatives of private industry.

II. Work process

1. Research Process

In order to situate ourselves within the problem space, we began with a literature review of local news articles, general research papers, and books about obesity at a global and national level. After these sources informed our thinking, we broadened our research to topics we felt could be related to obesity such as, transportation, food manufacturing, and the effects of crime and safety on physical activity. In addition we researched groups and initiatives currently working in Pittsburgh, like UPMC Children’s Hospital and Just Harvest among other programs devised to combat obesity locally.

To collaborate our findings online we used a variety of digital tools. To organize and setup documents, spreadsheets, and folders we used Notion, a project management software. Of particular benefit was Notion’s tree structure which allowed us to show how certain elements were framed and to what depth.

2. Mapping process for wicked problem map

In order to generate our wicked problem map, we began with an analog approach. We wrote full sentences about the causes of obesity on post-its and branched them under 6 main areas:

Government/Policy/Legal
Environmental
Social/Psychological
Technology/Infrastructure
Economic/Business
Physiological

For example a post-it under Economic/Business stated:
Tariffs and subsidies benefit glocal trade. They don’t integrate values or ethics

As we refined the map we separated our findings into further sub-categories such as Nutritional literacy, Globalization, Equity policies, Home dynamics, etc. We also made notes of stakeholders as they revealed themselves in these subcategories.

In order to begin making connections between the issues we had identified and make adjustments more easily, we moved our map online using Lucidchart. We began further separating primary from secondary causes, and causes from consequences.

Business & Economics / Advertising & Marketing as a category
Primary Cause: Tactics like character branding used to market unhealthy food to children, Result: Increased preference and consumption of unhealthy food for children

III. Wicked problem map

Adjusting the STEEP Framework

By doing this exercise, we discovered a need to verify generalized statements to ensure our assumptions did not creep into our map. When we approached the second stage of the map we decided to eliminate certain categories and focus on causes we could prove and were relevant in relation to Pittsburgh. We removed some social causes or infrastructure issues that seemed likely to increase obesity but were difficult to prove or had no correlation to Pittsburgh. We also removed categories in globalization which may be causing obesity in other countries but are not specific to Pittsburgh.

We used the STEEP framework for mapping the wicked problem of obesity. This framework examines root causes and experienced consequences of a problem through five types of factors: Social/Psychological, Technical/Infrastructure, Environmental, Economic/Business, and Policy/Governmental factors. It also provides structure to draw connections between these various areas.

Many of the consequences of obesity have a negative impact on the health and body of the obese person. In addition, many of the root causes of obesity can be found within our genetics and biological responses to food and our environments. These causes and consequences did not fall neatly into the existing STEEP factors, therefore, we added physiology in our analysis. Our resulting analysis was thus framed as STEEPP, with an extra P for the Physiological factors of the wicked problem.

Challenges and difficulties

As we began our research process, we mapped obesity as a worldwide wicked problem. For example, we read literature about trade policies through which the US exports subsidized crops to other countries in exchange for healthier goods, contributing to obesity outside the United States. However, as we began to frame our project around Pittsburgh and the local impacts of obesity, we left this piece of the global obesity puzzle out of our map.

Furthermore, we noticed that the STEEP factor with which an issue was associated could shift as we reframed the issue. For example, the engineering of food for palatability and fast consumption is a factor that ties into technology (we have the mechanics to make this happen at a large scale), environment (waste products and pollutants are produced during the process) and economics (businesses make money from these products).

Because of these overlaps, we carefully considered what kinds of connections existed between the causes and consequences across our STEEPP map. We determined three categories of connections to display: causes in one STEEPP factor that lead to consequences in another STEEPP factor; mutually reinforcing causes or consequences; and consequences or causes with similar manifestations (for example, two unrelated factors that both contribute to over consumption).

link to full map: https://pasteboard.co/IUhbw9p.png

Social

Social and psychological factors encompassed six directions: Dietary Habits, Physical Activity, Social Perceptions, Emotional and Social Eating, Nutrition Literacy, and Home Dynamics.

Unhealthy food is often offered in social contexts that are more centered around reward or eating for pleasure than around hunger. For example, cake is often served at birthday parties and retirement parties, holidays like Thanksgiving center around eating a meal together, and getting together for drinks can be a socially appropriate means of celebrating. These contexts make it difficult to avoid unhealthy food while still partaking in social events.

Food is also emotionally contextualized in addition to socially. For example, the risk of obesity is higher for those who experience adverse childhood experiences (ACEs) including physical abuse, sexual abuse, or psychological abuse, familial substance misuse or addiction, domestic violence, or parental incarceration. A study by Child Trends (which also included parent deaths and exposure to violence outside the home in their analysis) found that more than 40 percent of children in Pennsylvania are exposed to ACEs every year. The effects of these events can include obsession with food and binge eating, or in the case of sexual trauma, intentional weight gain for desexualization.

Technology / Infrastructure

We explored technology and infrastructure factors through Technology’s Impact on Habits, Food Access, Urban Infrastructure and Lifestyle, and Food Science and Technical Progress.

One trend in the US that has been ongoing for decades, correlating with the rise of obesity, is food being adjusted from its natural state. These changes, on the whole, lead food to be engineered for palatability and quick consumption, making it easy to overeat (Fat Nation, Jonathan Engel, p61). For example, we don’t need to content with feathers, skin, or bones to quickly consume chicken nuggets, which have also been imbued with extra calories and fats from the oil they were deep fried in.

At the same time, technology has contributed to the sedentary nature of our lifestyles (Engel, p33). The development of sprawling exurbs contributes to long car commutes, exacerbated by unreliable public transportation access. Not only do these trips contribute to air pollution in Pittsburgh, they exacerbate obesity via temporal tradeoff: time spent commuting cuts into the amount of time people spend exercising and preparing food rather than ordering takeout.

Additionally, as Pittsburgh has transitioned away from its history as an industrial city, it has lost around 400,000 manufacturing jobs in the past 20 years alone. These jobs often required physical labor, but now the jobs that remain center around operating equipment that performs this labor for us. Even in office jobs, technology like computers, email, and instant messaging have reduced the need to move around during the day and hinged our productivity on sedentary tasks.

Pittsburgh’s food landscape is also uneven, with the simultaneous existence of “food oasis” (clusters of grocery stores in urban areas) specifically in East Liberty, and the food deserts (areas of limited or no availability to healthy food options within a mile) where nearly 50% of the population in the city resides. Some of the organizations who have intervened to bring fresh food to these areas are using innovative technology. For example, Fifth Season is an indoor vertical farm that uses AI and robotics to efficiently grow greens locally.

Environmental

Environmental factors include Mining and Past Resource Exploitation, the Impact of Food Production on the Environment, and conversely the Environmental Impact on Food Production.

The relationship between food production and the environment appears to be cyclical: many agricultural practices in place today are harming the environment, and the unpredictability of weather patterns in a changing climate will lead to further issues surrounding food access as climate change worsens. In Pennsylvania, for example, agricultural runoff from manure accounts for 35% of the state’s phosphorus pollution, and chemical fertilizer runoff is the largest nitrogen pollutant of the Chesapeake Bay.

The physical landscape of Pittsburgh plays a role in accessing healthy food, too — according to Pennsylvania’s Department of Environmental Protection, there are around 60 abandoned coal mines within Pittsburgh’s city limits, which have been shown to contribute to sinkholes. Sinkholes can disrupt the circulation of public transit necessary to acquire healthy food. The topography of Pittsburgh, too, with all its rivers and hills, contributes to the difficulties of transportation infrastructure, and consequently accessing grocery stores, particularly affecting even further those communities that live in food deserts and have no cars or easy access to healthy food outlets.

Economic

Business and economic factors fell into the categories of Purchasing Power, Advertising and Marketing, Labor, and Big Food.

Kraft Heinz is one of the large companies to be headquartered in Pittsburgh — despite internal health and nutrition initiatives, the food products it produces are still heavily processed. This creates a conflict of interest for the local economy; 800 Pittsburgh jobs depend on strong Kraft Heinz sales, while the health of Pittsburgh citizens would be improved with reduced consumption of processed foods.

These are not the only conflicts of interest we found within business and economic factors: Coca Cola, among other food companies, has contributed sponsorship to the American Society for Nutrition and even funded their own research institute — the Global Energy Balance Network — to fund scientific research that downplays the connection between sugary drinks and weight gain, shifting the focus instead to exercise.

Policy

Categories of policy-related factors included Equity Policies, Initiatives and Fund Allocation, Public Funding, Labeling, and National Guidelines.

An underlying factor within policy influence was finances. Nutrition guidelines hold consequences for consumer purchasing decisions, so food industries have a stake in trying to sway the guidelines in their favor. And the United States Department of Agriculture, who releases the guidelines, has close ties to the meat industry. This leads some to suspect that the USDA’s decision to discount the recommendation of their advisory committee for the most recent National Dietary Guideline and refrain from explicitly recommending a low intake of red meat, was a result of meat industry influence.

The monetary side of the issue doesn’t stop there: annual national medical costs related to obesity are estimated to cost at least $147 billion in the United States, placing increased burden on the healthcare system and public health spending. More locally, Pittsburgh Port Authority bus system is reliant on funding from the State of Pennsylvania, and has to compete with other funding priorities for improvements.

Physiology

Physiological factors were grouped into six contributing directions: Medical Interventions, Lifestyle Factors, Fetal and Infant Development, Body Response to Overweight, Role of Genetics, Medication

The engineering of food has created a scenario in which individuals are both overweight and undernourished (Engel, p55); this creates physiological problems from infancy. Undernourished mothers give birth to infants whose fat cells proliferate at higher rates in response to available food, as if they have been primed for food-scarce environments (Engel, p14).

Medication, too, can have side effects that indirectly lead to weight gain. For example, an increased appetite can lead to over consumption; medication may cause fatigue, thereby reducing motivation to partake in physical activity. Ironically, even as being overweight can prompt insulin resistance and increase the risk of type II diabetes, the insulin used to treat Type II diabetes can cause weight gain through water retention. These types of side effects are especially problematic if the need for medication is ongoing.

This category also accounts for the body’s physiological responses to our modern lifestyles: stress and lack of sleep both contribute to physiological environments primed for weight gain. Stress releases the hormone cortisol, which prompts an increase of belly fat; the abdominal fat that surrounds our internal organs is especially problematic as it secretes hormones that cause further negative effects on the body (Engel, p15–16). Lack of sleep increases your appetite hormone (Ghrelin) and decreases satiety hormone (Leptin), which contributes to weight gain through decreasing your body’s resistance to over consumption.

Gaps and further exploration

For the most part, we focused our map on the root causes and negative consequences of obesity; there are also several positive initiatives to bring additional healthy food and physical activity to Pittsburgh. Through a USDA program called the Community Eligibility Provision, for example, kids can count on free school breakfast and lunch at Pittsburgh Public Schools. Phipps Conservatory has created a partnership with UPMC and other Pittsburgh organizations to create health programming titled “Let’s Move!” after Michelle Obama’s nationwide campaign of the same name.

IV. Stakeholder relations map

Our work process for the stakeholder map started while working on the wicked problem map. We were mindful in extracting the initial list of stakeholders from our map as we wrote out issues. We felt this accelerated the process and also allowed us to populate a large list of elements without disregarding any at first.

In the next phase, we moved on to classify and arrange this initial list on the physical canvas to try to generate groups of similar actors. Here, our analysis was guided by two factors:

1. By considering whether an actor was deemed relevant enough to keep under our wicked problem (eliminating those whose connections were potentially too vague or unclear),
2. By finding similarities among them to potentially cluster into groups.

After two rounds of discussion and re-arrangement of the pieces, a general agreement was reached to keep 13 groups that were labelled as follows: Environmental Groups, Food aid & Equity, Pharma & Medicine, Government, Consumers, Big Food & Food Industry, Transport, Marketing, Living organisms & Ecosystems, Producers/Farmers, Fitness & Dieting, Leisure, Food retail & Labor. We knew that these categories were broad and included different types of actors under them, but felt that keeping a high degree of granularity and diversity of areas would enrich our understanding of the problem in order to understand the relationships between them. These had emerged during our wicked problem mapping, so we took a little distance to also add any other actors that had been missed earlier.

For the third phase, we focused on drawing lines on a secondary canvas to identify three types of connections: synergies, oppositions and complex relations. Mapping these connections was hard and really time consuming. We struggled with two main things:

1. Our own mental models and understanding of the topic was very different. Although we had been doing research, we still had gaps to fill to either support our individual conjectures or reject them.
2. In many ways, a lot of the connections were difficult to categorize as either synergetic or oppositional because they included both aspects depending on the angle of analysis and stakeholder relationships beyond the scope of obesity. This meant acknowledging the value tensions and making certain assumptions that would push the lever towards synergistic or opposing connections.

A major insight we had through this exercise was the further questioning of the relevance of displaying certain actors under the larger clusters or keeping them at all. One of the questions that arose during this process was whether it was possible to select 3 stakeholders from this group by using the density of connections as guide along with what we felt were intriguing relationships. This was definitely the case for choosing to further focus on Consumers, Nutrition & Dieting and Big Food & Food Industry. Selecting Nutrition helped us realize that we needed to pull in some actors from the Pharma & Medicine cluster as well.

Generating clusters and moving on to finding affinity and discordance

In the fourth phase, we moved these three broad groups of actors to the canvas and renamed the Stakeholder groups as follows: Food Industry & Retail, Consumers, Health & Wellness. This was so we could more clearly capture the essence of the elements included which were further filtered to only keep the most different yet relevant ones. Again, although we understood that this diversity would make our future work harder, it felt necessary to keep diversity at first. At this point, our map focused on drawing connecting lines to represent areas of alignment and discordance.

A second iteration of this map, based on faculty and peer feedback, narrowed down our scope further to look at only one actor per group. Focusing on only three main stakeholders allowed us to make the process of speculating about affinity, agreements, disagreements or potential areas of conflict easier and clearer to identify particular concerns. We focused on the nature of connections between Health and Nutrition Specialists, Mothers and Lobbyists. As it can be seen in the final graphic, we opted to show different line weights for those connections that were stronger or more significant, and added descriptions of the relationship specifics to each line.

Some of the key speculations developed during this exercise included:

• Mothers depend on healthy diets to ensure healthy (less likely to become obese) babies. This is true before and during pregnancy, and while breastfeeding.
• Mothers living in food deserts (usually minorities) often rely on processed foods and fast foods if there are no larger grocery outlets or fresh food available.
• Diabetic mothers depend on advice, prescriptions and treatment delivered by doctors and nutritionists Nutritionists and doctors perform checks to assess BMI and determine risk of non-communicable diseases.
• Nutritionists and doctors receive national dietary guidelines that are influenced by food lobbyists pushing for specific food sectors.
• Researchers receive funds to perform studies that support claims to promote certain products or food groups. Lobbyists put pressure on local and national governments to determine nutritional advice (dietary guidelines) that is then replicated by healthy professionals.
• Lobbyists try to favor certain food sectors or food groups that increase revenue and not comply with scientific evidence.
• Lobbyists put pressure on market and trade policies which favour certain commodities determining low prices for ultra processed foods.
• Food lobbyists shape the type of information available on product labels often leading to confusing information.
• Lobbyists affecting labeling policies can directly affect purchasing decisions at the point of sale, with no regulations for terms such as “healthy” or “light”.

When outlining these speculations on the map, we further synthesized a few elements and tried to expand further while seeing how the green and red connections came into shape.

The final map leads us draw the following main insights:

1. There exists a conflicting relationship between Mothers and Lobbyists (Food Industry), because of simultaneous rejection and dependance. Thanks to socioeconomic drivers, minorities and lower-income mothers may need to rely on cheap, processed foods (due to lack of access or higher prices of fresh foods) or forgo groceries for fast food outlets. While it may not be their desirable choice, necessity forces this reinforcing depandance — the more they buy, the more lobbyists can point to industry demand.
2. There are significant power struggles between Lobbyists (whole food industry) and Health and Nutrition Specialists (including doctors, nutritionists and researchers) which derives in complex politics, ethics -as in conflicts of interests in research and bias, or tough negotiations on food-related policies about labeling and dietary guidelines.
3. The links between Health and Nutrition Specialists and Mothers, although still complex, tend to be more synergistic, resulting from mutual need and trust. The potential conflicts may have more to do with personal, social or cultural aspects, professionals’ ethos, or interpersonal relationships, rather than misaligned goals between these groups.

The iterative process of getting to this final stakeholder map helped us reflect on how STEEPP forces play into forming these complex relationships. For example, the power struggle between Lobbyists and Health and Nutrition Specialists has political and economic factors baked into it, but the outcomes manifest themselves in social and cultural constructs of the consumers.

V. Reflections, insights and lessons learned

Considering levels beyond the individual, such as institutional layers or socioeconomic dynamics within our topic and in the case of Pittsburgh, there is a very close relationship between infrastructural problems, policy and economics. There are big dichotomies whereby the economic improvements that can be perceived today have increased certain gaps among the population, especially affecting the vast number of people that are characterized as living in food deserts today in the city. Although obesity and food deserts don’t directly correlate, the social determinants of health do imply that those with least purchasing power or not protected by certain policies are in big disadvantage to be able to meet their diet-influenced health needs. This is evidenced in the high prevalence of obesity that exist among children and youth that impacts the city’s black and Latino minorities under the poverty line. However, there is a worrying dependence on the food sector as being historically and at present, a key employer in the area.

Not least important, at the level of the biosphere and the environmental implications, it is yet unclear how much attention is being put into the relationship that exists between the impact of food production on the environment and what this may imply for a healthy local food system, and even more so, the impact that this could have on the quality of these foods and the diets that they may enable. It became clear during our research that there is usually a tendency to highlight the socio-economic and psychological implications of the problem of obesity, and less, interest in understanding the implications and interrelations with environmental factors. This may mean that more research should be done to understand this weak link, which may potentially be linked to the historical development of the region as an area of massive resource exploitation. Not least important, the city’s topography and history of mining do play a key role in determining, mostly preventing, ease of access and circulation among different areas, again placing a burden on undeserved communities or disadvantaged individuals.

Beyond this, what became clear is that the framing of an issue will clearly determine how the problem may be found to be affected. The discourses and narratives, together with whether obesity was being framed as an epidemic, as a social issue, as a matter of inequalities, or other, can have large implications on how we may understand these links. It was interesting to see the different perceptions that exist within the group, whereby our backgrounds, life experiences and knowledge may shed light over certain aspects often arriving at opposing conclusions. In this sense, the whole process became one of constant discussion and negotiation of the elements to include, which we acknowledge, and became further clear, are important to keep in mind as the discrepancies were found in a group that still has some similarities (as similar “disciplinary” background). When speculating about stakeholders, the challenge posed by the different views on the problem became further evident, our ideas led us to make different assumptions and notice differing relations which made us wonder whether all relations are mostly highly complex as opposed to only synergetic or conflicting (as within our own group).

Another key insight during our work had to do with perceiving time as an important constraint, the complexity of the problem arises quickly and leads to more questions than answers, clearly showing that such analysis should desirably be made with more depth and research, both primary and secondary.

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References:

Julier, A., 2012. The political economy of obesity: The fat pay all. In Food and culture (pp. 560–576). Routledge.

Lobstein, Tim, and Hannah Brinsden. 2019. “Global Atlas on Childhood Obesity.” London. https://www.worldobesity.org/nlsegmentation/global-atlas-on-childhood-obesity.