**2. The pediatric obesity epidemic, global inequality and current recommendations**

The rise in obesity among adults is well documented. An alarming and relatively new problem is the rise of pediatric obesity. Childhood obesity in the United States more than doubled in children and quadrupled in adolescents from 1985 to 2015 [2, 3]. The CDC defines "over‐ weight" as excess body fat such that body mass index (BMI) is 25.0–29.9 kg/m2 and distin‐ guishes it from "obesity," which has BMI ≥30.0 kg/m2 (CDC, 2015) [3]. In recent years, it has become necessary to create another category, "morbid obesity" (BMI ≥40), sometimes referred to as Class 3 obesity, super obesity, or severe obesity, a phenotype that had previously been exceedingly rare among adults. From 1980 to 2012, obesity in children aged 6–11 years increased from 7% to nearly 18%, whereas obesity in adolescents aged 12–19 years increased from 5% to nearly 21%. Tragically, pediatric morbid obesity and its dangerous complications have lately become increasingly common.

Obesity is an alarming epidemic because of its comorbidities, which include diabetes, cardio‐ vascular disease [4], and based on new evidence, increased risk of some forms of cancer [5, 6]. Obesity‐driven diabetes, or Type 2 diabetes, was previously only a problem for adults and was termed "adult‐onset" diabetes, to distinguish it from "childhood" diabetes, or Type 1 diabetes, which is primarily immunological in origin. Unfortunately, Type 2 diabetes is now prevalent among children, which is a new development in human history and is driven by obesity. In fact, 90% of all Type 2 diabetes, with its life‐threatening complications, is obesity‐driven.

tions limit quality of life and ability to work, and exacerbate healthcare costs. The Centers for Disease Control and Prevention (CDC) in the United States have identified an "obesity epidemic" and specifically, reported in 2010 that 14.6% of children from 2 to 4 years old in low income households are obese. Extending current trends, the scale of the problem by the year 2030 will overwhelm healthcare systems globally. Obesity experts readily acknowledge that the etiology of pediatric obesity is multifactorial and will not be solved with single‐paradigm, single‐cause approaches. This "grand challenge" has thus already garnered the attention of experts across many disciplines, including medicine, molecular biology, public health, social

We add the field of organization studies to this list of disciplines, because it has a long history of examining problems that at once involve "agency and structure"—that is, the actions of individuals and the constraints of societal systems. We posit that the management of pediatric obesity is confronted by exactly this tension between agency and structure. On the one hand, recommendations about lifestyle choices abound. On the other hand, two distinct kinds of constraints are at play. Societal conditions shape diet and exercise options, such as the availability of fresh produce or the safety of nearby playgrounds, with the result that childhood obesity in the United States is strongly linked to lower socioeconomic class. In addition, the underlying biological nature of obesity is being increasingly explored, yielding insights into when and to what extent lifestyle adaptations can make a difference. Many biological pathways are set in childhood, and moreover, obesity may manifest with varied metabolic patterns, suggesting that the focus on lifestyle, or behavioral variables alone, is incomplete. Certainly, medical researchers and clinicians also appreciate the duality of individual behaviors and biological determinants. "Boundary spanners" across disciplines and sectors can advance work on obesity [1]. Adding the insights about agency and structure from an organization studies approach to the role of the corporation will, we propose, expand the analytical options

**2. The pediatric obesity epidemic, global inequality and current**

weight" as excess body fat such that body mass index (BMI) is 25.0–29.9 kg/m2

The rise in obesity among adults is well documented. An alarming and relatively new problem is the rise of pediatric obesity. Childhood obesity in the United States more than doubled in children and quadrupled in adolescents from 1985 to 2015 [2, 3]. The CDC defines "over‐

become necessary to create another category, "morbid obesity" (BMI ≥40), sometimes referred to as Class 3 obesity, super obesity, or severe obesity, a phenotype that had previously been exceedingly rare among adults. From 1980 to 2012, obesity in children aged 6–11 years increased from 7% to nearly 18%, whereas obesity in adolescents aged 12–19 years increased from 5% to nearly 21%. Tragically, pediatric morbid obesity and its dangerous complications

and distin‐

(CDC, 2015) [3]. In recent years, it has

policy, urban planning, early childhood schooling, and nutrition.

and rigor in approaching pediatric obesity.

196 Adiposity - Omics and Molecular Understanding

guishes it from "obesity," which has BMI ≥30.0 kg/m2

have lately become increasingly common.

**recommendations**

Pediatric obesity is increasing globally, as an externality of economic growth. There is an asymmetry in the link between obesity and socioeconomic class, such that in wealthy nations, obesity is prevalent among the poor, whereas in emerging economies, obesity is prevalent among the rising middle class. Anthropologists explain this asymmetry as a case of rising status being associated with what is scarce. In nations with abundant food and scarce time, being lean is scarce and may, ironically, require greater investments, such as prepared foods and gym memberships. In contrast, in emerging economies, food may be scarce and foods with popular global branding are regarded as luxuries or status symbols. Thus, in emerging economies, pediatric obesity is associated with an expanding middle class, as a history of scarcity gives way to more plentiful foods that are caloric but nutritionally inefficient, which are often globally sourced [7]. Consider some examples: Childhood obesity in Kuwait is increasing rapidly as wealthy children are frequently offered fast food as a fashionable treat, which has prompted the government to explore new diagnostic tools [8]. New wealth in Bangalore, combined with call center jobs that involve long periods of sedentary work, is raising the incidence of obesity‐related health problems [9]. World cacao reserves are depleting as Chinese middle class consumers develop a taste for chocolate, urged by American market‐ ers, for example, pushing Oreos in China as a food and a cultural "experience."

In contrast, in developed countries, pediatric obesity is related to poverty. Juxtaposition of two maps of the United States from the CDC [10], one showing the prevalence of obesity at US county‐level resolution and other showing the prevalence of poverty, represents this strong correlation. Time becomes the scarce resource in developed nations. There are strong pressures to work long hours, whether as a demonstration of commitment for professionals or to secure a livelihood for workers in low‐wage jobs. Time is required to prepare healthy meals in nuclear families and to exercise. The child development supplement (CDS) of the panel study of income dynamics (PSID) has been used to show that both maternal and pa‐ ternal long hours of work affect childhood obesity [11]. Parents who can allocate more time to their children can play a role in reducing pediatric obesity. "Shared parent‐child activities found to have an impact on childhood obesity included yard work, laundry, shopping, building or repair work, food preparation, talking, and reading" [11]. Also using the CDS of the PSID, maternal supervision of children and provision of nutrition were found to be small but significant mechanisms that mediated the relationship between maternal employ‐ ment and childhood obesity [12]. The prevalence of pediatric obesity, but not the mecha‐ nisms, varied by maternal education. It becomes too easy to designate "good" versus "bad" parenting strategies for managing childhood obesity and moreover, to infuse these conclu‐ sions with class‐based biases. Article titles such as "Do working mothers raise couch potato kids?" [13] show the impulse toward locating the problem in individual lifestyles and be‐ haviors. However, the problem of obesity and poverty in developed countries is more com‐ plex and involves structural factors, including economic policies [14].
