The nature of the relationship between obesity and mental health: an IMI2 SOPHIA qualitative study

Abstract

Introduction

Obesity is associated with poor mental health. However, the nature and direction of this association are not well understood. This study is the first to qualitatively examine the nature of the relationship between obesity and mental health from the perspective of people living with obesity.

Methods

A qualitatively-driven multimethod research design was implemented, integrating hermeneutic phenomenological conversational interviews and focus group methods. Data from these interviews were transcribed verbatim and analysed using thematic analysis.

Results

Four major themes emerged related to: (1) Mental health difficulties and obesity: Chicken or egg?, (2) Obesity as “a literal not fitting in”, (3) Obesity as a response to trauma, (4) The importance of mental health support in obesity treatment. People living with obesity struggled to determine the direction of the relationship between obesity and mental health, but identified the mental health impact of “not fitting in” and obesity as a response to, or repellent against, childhood abuse or trauma.

Conclusion

Our findings offer a qualitative insight into the bidirectional nature of the relationship between obesity and mental health from the perspective of people living with obesity.

Introduction

Mental health and obesity are established as major global health challenges [1]. Once a symbol of status and prosperity, overweight and obesity are increasingly conceptualised as socially undesirable and in opposition to thinness as the healthy ideal [2]. Studies have consistently indicated an association between poor mental health and obesity; however, the direction of this relationship is unclear [3–5]. Systematic reviews and meta-analyses of literature chart the elevated rate of mental disorders amongst people living with obesity, as compared to the general population [3, 6–8]. Further, epidemiological studies chart the increased likelihood of developing obesity amongst people with mental health difficulties [9–11]. One systematic review suggests that people living with obesity have a 55% increased risk of developing depression over time, whereas people with depression have a 58% increased risk of developing obesity [12]. While there is significant quantitative evidence establishing a relationship between obesity and mental health difficulty, the absence of qualitative research in the field of obesity has been documented [13]. Qualitative research approaches play a key role in locating complex diseases, such as obesity, in the social, cultural and economic contexts that are so intimately associated with their aetiology, treatment, trajectory and prognosis. Qualitative health research goes beyond single exposure-outcome causal pathways and “can catch what may otherwise be missed” [14] (p.1). Indeed, understanding the experiences, perspectives and priorities of people living with diseases such as obesity has been described as “the single more important tool of medical care” [15] (p.221). This study is the first known study to qualitatively examine the nature of the relationship between mental health and obesity.

Methods

Study design

This study adopted a qualitatively driven multimethod research design. Adopting more than one qualitative method offers the holistic worldview of approaching a subject from two different paradigms (in this case, interpretivism and constructivism) and the benefit of a sequential design where the development of method two (focus group) was informed by the findings of method one (conversational interviews) [16]. The study began with hermeneutic-phenomenological conversational interviews, which offered a broad, patient-led insight into the nature and meaning of living with obesity. Hermeneutic phenomenology, as an approach to research, is considered to sit within the interpretive paradigm—a paradigm that evolved from the Heideggerian view of the nature of being-in-the-world [17] and of humans as self-interpreting beings [18]. Data from the hermeneutic phenomenological conversational interviews [19] revealed that mental health was a key priority for people living with obesity and highlighted the lack of clarity as to the direction and nature of the relationship between obesity and mental health. These data informed the development of a focus group question aimed at understanding the nature of the relationship between obesity and mental health. In contrast to individual or group interviews, focus groups encourage interaction between participants: asking questions, sharing experiences, expanding similarities and differences in points of view and co-constructing an understanding [20]. As such, focus groups are particularly effective in exploring people’s knowledge and experiences and offer an insight into, “not only what people think, but how they think and why they think that way” [20].

Recruitment and participants

Each of the study’s two sequential methods had its own sample. This offered the advantage of the depth of working more closely with a smaller group of participants (n = 15) for the conversational interviews, as well as the representativeness afforded by a more diverse focus group sample (n = 30). For the first, conversational interview sample, a non-probability, convenience sample of participants was drawn from two Irish hospital-based weight management and diabetes management clinics. Convenience sampling, in contrast to probability sampling, does not aim to generate a sample representative of the entire population but rather “implies that a researcher is choosing informants because those informants might have something to say about an experience” (Steeves, 2000). In this case, the experience under study was the experience of living with obesity—operationally defined as BMI > 30 kg/m² and clinically understood as excess adiposity that impairs health [21]. As patients registered with hospital-based obesity clinics, all participants had been diagnosed with obesity. Having experience of mental health difficulty or a diagnosed mental disorder was not a condition of participation. Researchers generated a random list of patients and contacted each participant by telephone, inviting them to participate. The aim was to achieve a sample size of fifteen, a sample size that is considered suitable for studies of this nature that focus on depth rather than breadth or representativeness [22, 23]. Nineteen participants were contacted to generate the target 15, with four of those contacted choosing not to participate. The self-selection nature of participation is standard for convenience sampling, but results in a degree of self-selection bias that is inherent in non-probability sampling. The conversational interview sample consisted of n = 8 women and n = 7 men—with this coincidental gender balance a strength in a research area where women are more likely to participate in research than men [13].

Participants for the focus groups were recruited through four channels to broaden the representativeness of the sample. These were one Irish hospital-based weight management clinic (n = 7), as well as participants from three leading European and US obesity advocacy organisations: Obesity Action Coalition (OAC) (n = 9), European Coalition for People Living with Obesity (ECPO) (n = 6), and Irish Coalition for People living with Obesity (ICPO) (n = 8). The sample included 11 men and 19 women, of which 24 were European and 6 were North American.

Table 1 provides further detail on the full sample with those who participated in the conversational interviews delineated from those who participated in the focus groups.

Table 1.

Participant demographics.

Pseudonym	Sex	Method	Age range	Location
Ada	F	Conversational Interview	40–49	Europe
Amanda	F	Focus Group	40–49	Europe
Áine	F	Conversational Interview	60–69	Europe
Anna	F	Focus Group	40–49	Europe
Angela	F	Conversational Interview	30–39	Europe
April	F	Conversational Interview	30–39	Europe
Bob	M	Focus Group	60–69	Europe
Brianna	F	Focus Group	50–59	Europe
Caroline	F	Focus Group	50–59	Europe
Catherine	F	Conversational Interview	50–59	Europe
Camila	F	Focus Group	70–79	Europe
Cora	F	Conversational Interview	60–69	Europe
Damian	M	Focus Group	50–59	Europe
Daniel	M	Conversational Interview	40–49	Europe
Daniella	F	Focus Group	50–59	North America
Eddie	M	Focus Group	40–49	Europe
Freida	F	Conversational Interview	60–69	Europe
George	M	Focus Group	60–69	Europe
Graham	M	Focus Group	60–69	Europe
Harper	F	Focus Group	40–49	Europe
Isla	F	Focus Group	50–59	Europe
Keith	M	Conversational Interview	50–59	Europe
Kenny	M	Conversational Interview	60–69	Europe
Kimberly	F	Focus Group	40–49	North America
Layla	F	Focus Group	30–39	North America
Liam	M	Conversational Interview	60–69	Europe
Lydia	F	Focus Group	40–49	North America
Melanie	F	Focus Group	30–39	Europe
Max	M	Focus Group	50–59	North America
Maeve	F	Focus Group	60–69	Europe
Matteo	M	Focus Group	30–39	North America
Miriam	F	Conversational Interview	40–49	Europe
Olivia	F	Focus Group	30–39	Europe
Peadar	M	Conversational Interview	50–59	Europe
Ronan	M	Focus Group	40–49	Europe
Rory	M	Conversational Interview	40–49	Europe
Samantha	F	Focus Group	20–29	Europe
Stella	F	Focus Group	50–59	North America
Selina	F	Focus Group	30–39	North America
Susanna	F	Focus Group	50–59	Europe
Sonia	F	Focus Group	40–49	Europe
Steve	M	Conversational Interview	40–49	Europe
Taylor	M	Focus Group	60–69	Europe
Vihaan	M	Focus Group	50–59	North America
Walter	M	Focus Group	30–39	Europe

Data generation

The first of the study’s sequential methods involved a series of one-to-one in-depth hermeneutic phenomenological conversational interviews. These interviews were carried out online as they were conducted during a period of COVID-19 lockdowns (February–November 2021). The conversational interviews were open-ended, with each interview beginning with a single question: “can you tell me about your experience of living with obesity”. The interviewers (EF, EH) did not interrupt the participant except to clarify a point or detail (e.g. “that took place before you attended the clinic?”); describe what they had heard (“it sounds like that experience was extremely challenging”); or to invite participants to elaborate on the experience (“what was that like?”). This open approach offered participants the opportunity to share their experiences in their own words and in their own way without the curtailment of researcher-designed interview schedules or questions. A total of 15 interviews were carried out, ranging in duration from 45 to 105 min. The average interview length was over 1 h.

The findings from these open, patient-led, conversational interviews were used to inform the development of thematic priorities and an interview schedule for the second sequential, focus group, method. By virtue of being patient-led, these conversations allowed what was important to them to come to the fore, with the most frequently recurring themes identified as thematic priorities for further research. Mental health represented one of these thematic priorities and the question “Do you think that there is a relationship between mental health and obesity?” was presented, verbatim, to each focus group in order to initiate a group conversation about the nature of the relationship between obesity and mental health. Each participant was offered the opportunity to share their own personal reflections on mental health and obesity, with each account sparking resonance and remembrance in the other participants present and thus yielding a rich and layered conversation.

Data analysis

All data were analysed using Braun and Clarke’s [24, 25] six-step framework for thematic analysis. Firstly, each conversational interview and focus group recording was transcribed verbatim and initial analysis completed by one researcher (EF) using Braun and Clarke’s framework. This framework involved (a) becoming familiar with the data by reading and rereading the data in their entirety; (b) generating initial codes by jotting down descriptive labels and key words; (c) taking these initial codes and sorting them into potential themes; (d) reviewing and refining these prospective themes in terms of how accurately they reflected the meanings in the data; (e) further refining and defining these themes and what they revealed about the nature of the relationship between obesity and mental health; and (f) formulating the findings as a ‘whole’ and presenting them as described below. The wider research team (JN, EH, DMcG) was presented with findings at step (d) and step (f), and the ensuing discussion facilitated a degree of inter-rater reliability [23] and honed the thematic findings presented below.

Results

Analysis of the data yielded four themes: (1) Mental health difficulties and obesity: Chicken or egg?, (2) Obesity as “a literal not fitting in”, (3) Obesity as a response to trauma, (4) The importance of mental health support in obesity treatment. This section discusses each theme in turn. Select quotations are presented in-text using pseudonyms to protect participant confidentiality, with a more collated selection presented in Table 2.

Table 2.

Representative quotes organised by thematic findings.

Mental health difficulties and obesity: Chicken or egg? “You don’t know whether you’re thinking [negatively] because it’s a symptom of poor mental health or it’s a symptom of being fat. It’s a bit of a chicken and egg situation.” – Samantha. “Sometimes I think it’s hard to determine what comes first. Is it that many people who live with obesity have something mentally that challenges them, or they struggle with, and then they get obesity? Or, is it the other way around? [Are mental health difficulties] because of the stigma that comes with living with obesity, and the blame and the shame?” – Sonia. “I wouldn’t say that mental health is like linked to obesity but obesity can impact on mental health” – Bob. “I’m not sure how much of the depression and anxiety that is associated with obesity is actually because of obesity, or the stigma.” – Kimberly.

Obesity as “a literal not fitting in” Weight is a literal not fitting in. Like, you have to go to a space and go well, “will I fit in this chair?”, “am I going to be comfortable in a movie theatre or a doctor’s office?”, “will they have a blood pressure cuff that’s going to fit me?”. “Am I going to be able to find clothes in this shop?”. “Will I have a wedding dress that’s going to look anywhere close to beautiful?” – Lydia. All of these things that people who don’t live with obesity take for granted. People with obesity think about constantly, because you just can’t take for granted that there’s a spot - every party, every restaurant, every airline, it is a literal question of, will I fit? Is there space for me? And no one should have to think about, is there space for you - there should be space for people, we should be allowed to take up space. And the very question that people living with obesity are forced to endure every day, creates mental conflict” – Lydia. And when you have obesity, you’re never not thinking about it – you’re always thinking about it. It’s just like this gnawing voice in the back of your heard, you’re worried about what people are going to think of you, what are they going to say, or will I fit in this place, or they’re going to have a chair big enough for me. You’re always thinking about it, and it takes up so much brain power – Kimberly. I’m always conscious of being larger – […] if you’re going for a walk. Are you going to overheat because you’re carrying extra weight? so your heart is working harder? This sort of thing. How you look, the image you present when you walk out the door, how you’re dressed. I think, in my head, I think people, they do look, there’s no doubt about it. Because you’re not the average person just passing up and down the street, you are a larger person. Even going into a restaurant, where the table is? whether you’ll fit in the chair? whether you’ve to get past somebody? And maybe a size 10 or 12 or whatever doesn’t even think about this, but for a larger person, you’re straight away, you’re inconveniencing somebody – Catherine. I think if you if you are slim, life is easier, you know – Keith.

Obesity as a response to trauma What I’ve learned from my own personal experience is that we generally become obese, because as young people we’ve suffered some kind of trauma that we haven’t dealt with, and we turn to food because food makes us feel good. There’s just some wonderful feeling about eating and it makes you feel good, it allows you to escape – Max. For me, I was sexually assaulted from the time I was 12 until the time I was 17 by my older brother - and for me, food was my escape. If I was ugly, if I was fat, he would leave me alone. And what I learned in time was, it had nothing to do with that, it had to do with power. But the mental health side of things, you fall into this depression, and I think that obesity, those that live with obesity, are traumatized on a constant basis – Max. I think in some ways I wanted to make myself ugly because I didn’t want that [unwanted sexual] attention you know and then my mom’s boyfriend made a lot of comments, sexual comments about me as well, when my mom wasn’t around and at one point [he] attacked me as well and […] even though I wanted to look good I didn’t feel comfortable being sexually attractive to men – Ada. Things happen in your childhood, and it’s the way things went down and that’s life, you know. I think it’s more though. I would say I comfort eat a lot over life. I always have done – Keith The reason I had a weight problem was in my head, the battle for me losing weight was in my head. […] I mean, I ate when I was happy, I ate when I was sad. I ate to celebrate; I ate to commiserate myself. So, that just told me that it’s a head-game – well, for me it was a head-game – George. I can actually go back to a traumatic event in my life that happened and that’s when it all started with me – Susanna. I think they [mental health and obesity] just go hand in hand because the worse you feel about yourself, the less you take care of yourself and the less inclination you have to help yourself. And you can get to a stage where you just sort of give up and think what’s point? I have no worth as a human so what’s the point in trying, you know? So, it can be very difficult – Amanda. [You] just feel disgusted in yourself. Like you’re just a less than person and you just like feel it’s all your fault that you got to this state and you’re disgusting looking and you’re a disgusting person and you know. No one could love you so you know you can’t love yourself, so I could anyone else love you and all that kind of thing you know. It’s just like horrible like the way your mind you know, goes against you like that, you know – Amanda.

The importance of mental health support in obesity treatment I don’t know anyone who has lived with obesity, who would not benefit from therapy or the ability to process how society’s view of obesity has affected them – Lydia. It’s in the mind as well you know, you know it’s in your mind – Angela. If we could deal with mental health, and if we could have people talking about the reasons why they are emotional eaters, or why they’re eating out of control, if we could get that under control, and we could have more healthcare that is mental healthcare, I think we would have less cases of obesity – Max. I don’t think [the mental health effects of obesity surgery] is spoken about enough. I see people and they go abroad, they come back and months later they’re wondering why they’re feeling terrible. But they need…, you actually need the mental health support. Because, the surgery, or whatever treatment options people get for obesity, doesn’t fix your mindset – your mindset is still… as I said, I don’t know which one causes which [mental health difficulties causes obesity or obesity results in mental health difficulties], but the mind is still quite broken, the mind needs to be rebuilt – Sonia. I think that it is a mental issue as well, that there should be something in the health system […] that would actually help you on your journey and advise you along the way because it helps to have somebody to talk to you about your eating issues – Damian.

Mental health difficulties and obesity: chicken or egg?

Participants in the study’s two qualitative methods considered, often at length, the nature and direction of the relationship between mental health and obesity. Sonia spoke about how “it’s hard to determine what comes first” while Samantha considers it “a bit of a chicken and egg situation”. Kimberly, however, locates the source of the poor mental health associated with obesity on the stigma “I’m not sure how much […] is actually because of obesity, or the stigma”. What is interesting to note in relation to this theme is that, in spite of considerable reflection and consideration of the moderating role of stigma, judgement and prejudice, participants did not succeed in establishing the direction of the relationship between obesity and mental health—or, to paraphrase Samantha, which came first, the chicken or the egg.

Obesity as a “literal not fitting in”

Participants described “weight [as] a literal not fitting in”. The many ways in which people living with obesity are made to feel like they don’t fit in permeated the hours of interviews and focus groups. These included not being able to fit into a chair, or a booth at a restaurant, or an aeroplane seat, or a train seat. They included not being able to fit into their own car if somebody parks next to them in a car park and if they’ll be able to fit into the clothes available on the high street, and, if they do, if they will be appropriate or flattering. Shoes, boots, gloves, medical gowns, blood pressure cuffs, blankets—not to mention MRI machines or other medical essential equipment—were all mentioned by the 45 participants as being ways, things and places in which they don’t fit. The need to fit in, to belong, has long been recognised as “an irreducible human need” [26, 27]. The state of unbelonging, of not fitting in, has a hugely deleterious impact the mental health and well-being [28, 29]. It is one “that people living with obesity are forced to endure every day” (Lydia). It is one that “takes up so much brain power” (Kimberly) and that many participants described as being “always conscious of” (Catherine). Catherine spoke about the experience of being-in-the-world in a larger body: “you’re not the average person just passing up and down the street, you are a larger person”. For Catherine, being a larger person meant that “straight away, you’re inconveniencing someone”. To fit in, to feel as if you aren’t inconveniencing someone by your mere presence, would make, in Keith’s words, “life easier, you know?”.

Obesity as a response to trauma

Building on the “chicken or egg” theme, the third thematic finding points to participant’s experiences of traumatic life events, particularly early childhood trauma, and the links they draw between these and their obesity. It is important to note that this study did not directly ask about trauma or Adverse Childhood Experiences (ACE). The fact that these were brought up by participants themselves, further reflects their pervasiveness and raises the question of how many participants would have reported traumatic experiences if they had been asked directly. Max described his weight gain as a strategy to cope with, and avoid, the sexual abuse he was subjected to as a child by his older brother. “For me, I was sexually assaulted from the time I was 12 until the time I was 17 by my older brother—and for me, food was my escape. If I was ugly, if I was fat, he would leave me alone.” (Max). He described how food helped him “feel good”, how it was something he could “turn to” because “it makes you feel good, it allows you to escape” (Max). Ada spoke about the unwanted sexual advances she received from older men, including her mother’s boyfriend, when her body began to develop prematurely as a child. She says “I think in some ways I wanted to make myself ugly” and turned to food as a way of coping and making herself “ugly”. Keith, George, Susanna and Amanda all made references to “things that happen in your childhood” (Keith), without necessarily offering further information on what these ‘things’ are. What is clear, however, was that food acted as a response, a “comfort” (Keith), a “feel good” (Max) behaviour, a “giving up” (Amanda).

The importance of mental health support in obesity treatment

What each of the first three themes serve to highlight is the importance of mental health support as part of a holistic treatment response to obesity. This point was raised by participants on several occasions—just some of which are represented in Table 2. Lydia says she doesn’t know anyone living with obesity “who would not benefit from therapy”. For Lydia, this was primarily to “process how society’s view of obesity has affected them”. Max shared this view but suggested that therapy could enable people to understand “the reasons why they are emotional eaters”. He suggests that if mental healthcare was more readily available “we would have less cases of obesity”. For Sonia, mental health support would enable people to deal, not just with the stigma of obesity or “the reasons” as Max suggests, but to process and manage the effects of obesity treatment. She says that weight loss alone “doesn’t fix” obesity and that “the mind needs to be rebuilt” (Sonia) too.

Discussion

This qualitative multimethod study was designed to understand the nature of the relationship between mental health and obesity. It addresses a gap in the literature, which, to date, has dominated by quantitative studies of the rates of mental disorder amongst people living with obesity [3, 6–8] and studies of the rates of people with mental health difficulties who develop obesity [9–11]. What this study adds is a novel insight into patients understandings of the relationship between obesity and mental health. Further, it highlights variables, such as the prevalence of childhood trauma amongst people living with obesity, which, although independently recognised in the literature [30, 31], are often lost in the cracks of obesity science and practice. Thirdly, this study offers a unique insight into what it is like to be a person with obesity in the world. In illuminating the “mental conflict” (Lydia) of being in a bigger body in a world in which you don’t fit, and the sense of always “inconveniencing someone” (Catherine) by your very presence, this study brings these less acknowledged, yet essential, aspects of the nature of the relationship between mental health and obesity into view. This discussion section further advances these three original contributions to the literature by considering each of the study’s thematic findings in turn.

The question of whether mental health is “the chicken or the egg” when it comes to obesity was foregrounded by participants in both of this study’s two sequential methods. While there is a known relationship between obesity and mental disorder, the literature has thus far been unable to conclusively explicate this relationship. For example, obesity has been associated with depressive symptoms in five meta-analyses of studies from North America, Europe and Asia, with sample sizes ranging from 12,635 to 1,257,109 [3, 6–8]. However, the direction of this association remains unclear—is poor mental health a risk factor for obesity or is obesity a risk factor for poor mental health? Steptoe and Frank (2023) posit that this relationship is bidirectional but suggest that “the most convincing findings are that greater body weight leads to psychological distress rather than the reverse”. They attribute this to the psychological stress of weight stigma and discrimination experienced by many people with obesity which, in itself, is associated with increased risk of mortality [32]. However, the authors do note the dearth of high-quality studies, particularly studies that examine the association of obesity and mental health over time. As the first study to qualitatively explore this association between mental health and obesity, it is clear that people living with obesity are as unsure about the direction of the association as the literature. As Samantha said, “it’s a bit of a chicken and egg situation”, and while there are tentative findings that suggest obesity is “the egg”, this finding reinforces the importance of psychological support for people living with obesity. While the new generation of glucagon-like peptide-1 (GLP-1) analogue medications has resulted in significant optimism for weight loss and improved physical health for many people living with obesity, it remains to be seen if they are similarly effective in improving the mental health of people living with obesity [33]. As studies reporting increased levels of suicidality and suicide attempts amongst post-bariatric surgery patients who have lost weight [34] reinforce, the association between body weight and mental health is complex.

A second major finding foregrounded by this study was the experience of obesity as “a literal not fitting in” (Lydia). Fitting in, or belonging, is an irreducible human need [27] and essential to our well-being as humans [26]. Belonging is the need to be part of something, to experience real connectedness for who we are and what we bring to the world. Participants in this study described the “mental conflict” (Lydia) or the “gnawing voice in the back of your head” (Kimberly) they “are forced to endure every day” (Kimberly) as try to navigate a world in which they don’t fit. Much has been written about the physical barriers faced by people with obesity in accessing essential services and public spaces [35–37] and the psychological impact of the stigma and discrimination faced by people with obesity [38–40]. Less is known, however, about the psychological burden of “not fitting in” (Lydia). As Kimberly says “you’re always thinking about it, and it takes up so much brain power” and increases the psychological demand of even the most everyday of tasks: “when you have obesity, you’re never not thinking about it—you’re always thinking about it”. Catherine, in particular, described the psychological effort involved in the presentation and management of the self [41] for people in a larger body: “How you look, the image you present when you walk out the door, how you’re dressed. I think, in my head, I think people, they do look, there’s no doubt about it. Because you’re not the average person just passing up and down the street, you are a larger person”. What these insights serve to highlight is the daily psychological burden of living with obesity. They take us beyond the adverse effects of stigma, discrimination and the inaccessibility of environments for people with obesity, and take us into the less explicit psychological “self-presentation” [41] demands of being-in-the-world [42] in a larger body. Further, in illuminating the nature of the negative link between living with obesity and mental health, this finding reinforces calls to discredit any value, implicit or otherwise, that clinicians, the media, and the public place on fat shaming [4].

The relationship between obesity and trauma, particularly childhood trauma, has been recognised. Indeed, one of the lead investigators on the influential Adverse Childhood Experiences (ACE) Study, Dr Vincent Felitti, first recognised the relationship between trauma and physical health when listening to the life histories of patients at his obesity clinic. The Adverse Childhood Experiences (ACE) study was the first to demonstrate that the greater degree of adversity a child has been exposed to, the greater the risk of addictions, mental health issues, and medical problems they faced in adulthood [30]. A number of major studies have identified an association between adverse childhood experiences and obesity [43–46]. A recent systematic review and meta-analysis of studies on adverse childhood experiences and adult obesity identified a 46% increase in the likelihood of adult obesity following exposure to multiple ACEs [31]. Potential mechanisms for this increased risk include increased cravings in response to elevated stress [43], “food addiction” [44], the impact of repeated stress on glucocorticoids leading to increased intra-abdominal fat deposits [47] and changes in health behaviours including smoking, eating, exercise and sleep, with a resultant adverse effect on human health [31]. What is lacking from the literature is a patient-led, qualitative, understanding of the relationship between childhood trauma and obesity. Participants in this study offer a brief insight into the lived experience of childhood trauma and obesity. They breathe life into statistical hypothesis regarding potential mechanisms—for example that stress increases food cravings (“we turn to food because food makes us feel good” Max). Moreover, this study sheds light on the more nuanced mechanisms beyond the scope of quantitative measures. These include weight as a strategy to repel an abuser (“If I was ugly, if I was fat, he would leave me alone” (Max); “I wanted to make myself ugly because I didn’t want that [unwanted sexual] attention” (Ada)). What this study points to is the need for a qualitative participatory understanding of the relationship between trauma and obesity in order to augment quantitative studies in developing a comprehensive understanding of the mechanisms of action between childhood adversity and adult obesity.

Finally, reflecting this study’s four major thematic findings and the views of people living with obesity [48], this study recommends the inclusion of mental health supports, such as counselling or other talk therapies, as part of a holistic and comprehensive healthcare response to obesity. As the psychological effects associated with the new generation GLP-1 medications remain, as yet, unclear, this study’s findings regarding the complex nature of the relationship between mental health obesity indicate that sustainable long-term weight loss and health gain require both physical and mental health interventions.

Disclaimer

The communication reflects the author’s view and neither the IMI nor the European Union, EFPIA, or any Associated Partners are responsible for any use that may be made of the information contained therein.

Author contributions

EF conceptualised and designed this research in collaboration with JN. Data were generated and analysed by EF and EH. EF drafted the initial manuscript with input from all authors. The broader research funding was secured and managed by ClR with support from DMCG. All authors have approved and contributed to the final written manuscript.

Data availability

The datasets generated during and/or analysed during the current study are not publicly available due to their personal and sensitive nature but are available from ClR on reasonable request.

Competing interests

ClR has served on advisory boards for Novo Nordisk, GI Dynamics, Keyron, Sanofi, Boehringer Ingelheim, Herbalife, Johnson and Johnson, whilst receiving grant funding from Science Foundation Ireland, The Health Research Board and the Irish Research Council. The other authors have no conflicts of interest to report.

Ethics approval and consent to participate

Ethical approval for this study was granted by UCD’s Human Research Ethics Committee (HS-20-12-McGillicuddy) and all methods were performed with the relevant ethical guidelines and regulations. Participants were aware that they could withdraw their participation at any stage without consequence. Informed consent was obtained from participants both in written form, in response to the study information sheet, and verbally before each interview and focus group.