Impaired boundaries, sense of self, and personal control: the lifelong trajectory of co-occurring obesity and adverse childhood experiences for adult women.

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Learn more: PMC Disclaimer | PMC Copyright Notice Int J Qual Stud Health Well-being . 2026 May 29;21(1):2673595. doi: 10.1080/17482631.2026.2673595 Impaired boundaries, sense of self, and personal control: the lifelong trajectory of co-occurring obesity and adverse childhood experiences for adult women Mary Christine Jared a , Brian Koehler b, * , Sally S Cohen c Author information Article notes Copyright and License information a Yeshiva University, Katz School of Science and Health, Nursing Program, New York, USA b New York University, Silver School of Social Work, New York, USA c New York University, Rory Meyers College of Nursing, New York, USA * CONTACT Brian koehler bk64@nyu.edu Silver School of Social Work, New York, USA Roles Mary Christine Jared : Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing Brian Koehler : Supervision, Validation, Writing – review & editing Sally S Cohen : Supervision, Validation, Writing – review & editing Received 2025 Aug 28; Accepted 2026 May 10; Collection date 2026. © 2026 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( http://creativecommons.org/licenses/by-nc/4.0/ ), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent. PMC Copyright notice PMCID: PMC13224687  PMID: 42216483 Abstract Purpose To deepen the understanding of the phenomenon of co-occurring obesity and ACEs for adult women. Methods A qualitative, phenomenological, Reflective Lifeworld Research (RLR) approach was used. Fourteen women living with obesity (BMI ≥ 30) who were between the ages of 18 and 64, and who had at least one ACE participated. Results The results revealed three essential meanings of the phenomenon: a boundaryless childhood existence, being in and out of control, and a vague or distorted sense of self. Six intertwined constituent meanings further elucidate the phenomenon: obesity as an existential response to ACEs; a chaotic, abusive existence with caregivers; indoctrination into the world of food misuse, weight concerns, and body focus; the critical gaze of others and its impact on the self; burdened with obesity and other persistent health conditions, and adult perspectives on surviving life's challenges. Conclusions The women's existential struggles with their bodies and self-worth are compounded by the early genesis of ACEs, the violence and upheaval from ACEs, and the lifelong impact of co-occurring obesity and ACEs. Novel ways for treating co-occurring obesity and ACEs in women are presented. Implications for practice that include establishing concurrent obesity and ACEs management strategies to achieve better health outcomes for women seeking assistance in health care settings are included. Keywords: ACEs, adverse childhood experiences, emotional abuse, mental health, obesity, physical abuse, psychology, sexual abuse, women's health, family dysfunction Introduction Since the late 1970s, obesity, defined by the World Health Organization (WHO) as “abnormal or excessive fat accumulation that presents a risk to health” (World Health Organization, n.d. , para 1) and most often determined by using the measure of a body mass index (BMI) ≥ 30, ( WHO, n.d. ; CDC, 2025 ) has become a major United States (U.S.) public health crisis (Ng et al., 2014 ; Pereda et al., 2009 ; Temple, 2022 ; Trust for America's Health, 2022 ). Domestic and worldwide rates have nearly tripled since 1975. Between 2017 and 2021, U.S. obesity rates reached record historical levels: 42% of the US adult population (approximately 100 million individuals) were living with obesity (Centers for Disease Control and Prevention [CDC}, 2022a ; CDC, 2023b ). With respect to relying on BMI to determine a person's obesity status, it is key to recognize that in 2023, the American Medical Association (AMA) enacted a significant policy change on the use of BMI to define healthy weight; the intent for this major reform is that it will lead to a decrease of weight stigma in healthcare settings. The AMA reported that the use of BMI has proved to be insufficient for diagnosing obesity for both individuals and diverse groups. Recommended measurements that include waist circumference, evaluating genetic causes, and providing visceral fat assessments should be used instead in efforts to establish a person's health risk associated with their body habitus and adiposity (AMA, 2023 , as cited in Jared, 2026 ). In addition, in 2025, a global panel of 58 clinical experts and individuals living with obesity published a report and consensus statement that built and expanded upon the AMA recommendations. The international commission published a revised definition of obesity as “excess adiposity”, and identified two categories of obesity, pre-clinical and clinical, based on whether impacted persons suffer from organ compromise or restricted daily activities. Furthermore, they recommend that providers utilize other ways to measure obesity (e.g. weight circumference, waist-hip-ratio) in addition to BMI, and to consider a person's age, ethnicity, and gender when making a diagnosis of obesity (Brown, 2025 ; Rubino et al., 2025 ). From 2011 to 2014, compared to men, women in the US had almost double the prevalence of severe obesity (9.9% versus 5.5%) regardless of race or ethnicity (Centers for Disease Control & Prevention, 2015 ; Ogden et al., 2015 ). Women spend close to twice as much money on weight loss supplements as men (Austin et al., 2017 ; Pillitieri et al., 2008 ); they are more than twice as likely (18% versus 8%) to have ever used prescription medications for weight loss (Montero et al., 2023 ) and use more invasive weight loss measures such as bariatric surgery at rates of four times those of men (Young et al., 2016 ). Eighty one percent of adults who are prescribed glucagon-like peptide-1 receptor agonists (GLP-1s) are women (Edwards, 2023 ). Obesity can have harmful effects on women's mental health. It is often associated with depression and anxiety and can lead to poor interpersonal relationships, decreased employment opportunities, and unfavourable economic outcomes (Kasen et al., 2008 ; Puhl & Heuer, 2010 ; Segal & Gunturu, 2024 ). Obesity treatments since the mid-20th century have largely been directed toward modifications in diet, increased exercise, pharmaceutical therapies, cognitive behavioural therapy, and bariatric surgery (Fildes et al., 2015 ; Haga et al., 2019a ; Konik & Smith, 2015 ; Market Data Enterprises, 2019 ; National Institute of Health. National Institute of Diabetes et al., 2018b ; Rothblum, 2018 ). Generally, they have not led to sustained weight loss for many obese women (Evert & Franz, 2017 ; Nordmo et al., 2020 ). And while GLP-1 agonists have revolutionized the weight-loss trajectory for millions of women and have also been found to have other beneficial effects on reproductive and menopausal phases of life (Malesu, 2025 ), multiple studies have shown that once a person discontinues the medication, weight gain follows (Idrees & Umpierrez, 2023 ; Kubota et al., 2023 ). In addition, more evidence is needed on long-term sequelae and effectiveness of these medications for women (Perdomo et al., 2023 ; Popoviciu et al., 2023 ). In 1995, a team led by Dr. Vincent Felitti and the CDC launched an in-depth research investigation to explore the relationships between early childhood abuse, neglect, or familial discord, termed adverse childhood experiences or (ACEs) and obesity (and other chronic health conditions) in adulthood (Felitti and Jakstis, 2010 ; Felitti et al., 1998 ; Felitti, 2019 ; Williamson et al., 2002 ). Felitti and his colleagues defined ACEs as traumatic events in a person's early formative years (prior to age 18) that have been found to increase the risk of developing enduring and debilitating physical and mental health conditions in adulthood (Felitti et al., 1998 ; Iniguez & Stankowski, 2016 ). Remarking on the fact that ACEs are both widespread and extremely harmful, Felitti ( 2002 ) stated, “this combination makes them one of the most important, if not the most important, determinants of the health and well-being of the nation” (p. 46). The more ACEs a person has, the more likely they are to experience negative physical and mental health outcomes, severe obesity, and substance misuse and addiction in adulthood (Gondek et al., 2021 ; National Council of State Legislatures, 2022 ). This graded, dose-response effect is more detrimental for persons with four or more ACEs. In the USA, women are 50% more likely than men to report five or more ACEs (Felitti et al., 1998 ; Felitti, 2002 ; Merrick et al., 2018 , 2019 ; Waite & Ryan, 2019 ). These findings, with few exceptions, have not been integrated into the provision of health care for obese women seeking weight management treatment (Boynton-Jarrett et al., 2012 ; Danese & Tan, 2013 ; Hemmingsson et al., 2014 ; Kalmakis & Chandler, 2015 ; Merrick et al., 2018 ; Minnesota Department of Health, 2011 ; U.S. Preventive Task Force, 2019 ; Williamson et al., 2002 ). One possible reason for this is that clinicians and obese women, themselves, may have a limited understanding of the phenomenon of co-occurring obesity and ACEs (Jared, 2019 ; Kalmakis et al., 2017 ). Clinicians may also be hesitant to ask about ACEs because of entrenched social taboos (Felitti, 2002 ); or they lack clinical training to address what may be revealed and to whom the patient may need to be referred (Jared, 2019 ; Kalmakis et al., 2017 ; Weinreb et al., 2010 ). In the absence of information about a woman's ACEs and their meaning to her, however, comprehensive obesity treatment plans that could potentially improve a woman's sense of health and well-being may fail (Felitti et al., 2010 ; Felitti, 2002 ). Knowledge gaps about co-occurring obesity and ACEs for adult women justify using an empirical, person, and meaning-oriented approach to investigate this topic; previous substantial reliance on positivistic, quantitative methodology limits understanding of the meaning of co-occurring obesity and ACEs for adult women. Therefore, the purpose of this study is to explore the way in which the phenomenon of co-occurring obesity and ACEs presents among adult women. Materials and methods The study design was qualitative phenomenological with an open, reflective lifeworld research (RLR) approach (Dahlberg et al., 2008 ). The intent of RLR is to reveal the meaning structure of a phenomenon, based on how persons experience events in their life contexts (Dahlberg & Dahlberg, 2019 ). Drawing on the work of renowned philosophers such as Edmund Husserl, Maurice Merleau-Ponty, Hans-George Gadamer, RLR researchers endeavour to conduct empirical studies that are based on a phenomenological philosophy of science. RLR investigators aim to break down false epistemological and ontological dichotomies that are traditionally acknowledged as key differences between descriptive and interpretive phenomenology (Dahlberg & Dahlberg, 2019 ; Dahlberg et al., 2008 ). RLR optimized the discovery of meanings related to the phenomenon of co-occurring obesity and ACEs among adult women (Dahlberg et al., 2008 ). An open attitude toward learning about the phenomenon is a key component of RLR. This openness means that the researcher is available to the phenomenon to both perceive how the item of study reveals itself and to understand it in a new way. Openness is manifested through bridling (Dahlberg et al., 2008 ; Moodley, 2009 ). Bridling involves a movement between suspending and embracing the researcher's judgments about the phenomenon; it requires the researcher to continually analyze their ongoing interpretation to remain open about the phenomenon (Dahlberg et al., 2008 ; (Dahlberg & Dahlberg, 2019 ; Vagle, 2018 ; van Wijngaarden et al., 2017 ). Participant recruitment Institutional Review Board (IRB) approval was obtained for this investigation from the New York University Grossman School of Medicine Institutional Review Board (Research Study #: i21-00551) because as the study was launched, the initial intent was to recruit patients from NYU Langone Health, working collaboratively with a physician there. When recruitment lagged, additional ways of recruiting were developed, some of which included the NYU Langone Health Research Registry. There was no need to change IRBs at that point because the research proposal that NYU Langone Health's IRB approved included recruitment strategies that included and were not limited to NYU Langone Health patients. New York University Rory Meyers College of Nursing (where both Professor Cohen and the lead author were based) has an affiliated relationship with the New York University Grossman School of Medicine. This relationship enables nursing students and faculty to apply for IRB approval for studies that recruit patients from NYU Langone Health, which this study did. Written informed consent for the study was obtained from participants prior to the start of study procedures. Informants who differed in demographic measures such as age, race, ethnicity, income, partnered status, education, work status (unemployed or employed; employed in or outside of the home), BMI, or ACE types were included to enhance the potential for revealing a variety of experiences and novel meanings about the phenomenon (Dahlberg et al., 2008 ). This was achieved by having multiple participant recruitment venues and strategies. The participant pool was drawn from four sources: (a) in-person and online patient referrals from healthcare clinicians at an urban health care organization's weight management program, (b) a database of clinical trials and research studies registry from the same organization, (c) online searching for non-identifiable volunteer profiles on the ResearchMatch website (Harris et al., 2012 ; ResearchMatch, 2020 ), and (d) an urban university's media services and social media platforms. In addition, one participant was referred to the study by another participant. At their study visit with research personnel, potential participants reviewed and signed an online informed e-consent and completed a study eligibility screening form through REDCap, a secure web application for collecting data and constructing electronic surveys. Criteria for participation included that the person identified as female, that they were between the ages of 18 and 64, that they had a self-reported BMI ≥ 30, that they had a history of at least one self-reported ACE, and that they were willing to take part in a 50-minute Zoom interview. In addition, they needed to be able to speak, write, and understand English. (See Table I for demographic characteristics of the participant group). Table I. Baseline characteristics of the participants. Characteristic Participants ( N = 14) Age group Number (%) 18–24 1 (7) 24–34 4 (29) 35–49 2 (14) 50–64 7 (50) 65–79 0 80+ 0 Sex Female 14 (100) Race African American 4 (29) American Indian or Alaska Native 0 Asian 0 Native Hawaiian or Pacific Islander 0 White 9 (64) More than one race 1 (7) Choose not to respond 0 Ethnicity Hispanic or Latino 1 (8) Non-Hispanic or Latino 9 (69) Other 2 (15) Choose not to respond 1 (8) No response 1(8) Household income Under $13,999 3 (22) $14,000–$39,999 1 (7) $40,000–$69,999 4 (29) $70,000–$109,000 2 (14) $110,000–$249,000 2 (14) $250,000 and above 1 (7) Choose not to respond 1 (7) Relationship status Single 7 (54) Partnered 0 Married 5 (38) Divorced 1 (8) Widowed 0 Other 0 Choose not to respond 0 Highest level of education Less than a high school diploma 0 High school diploma 0 Some college 3 (21) College graduate 6 (43) Master's degree 5 (36) Doctorate 0 Other 0 Employment I work in the home as a caregiver 0 I work in the home managing a household 1 (7) I work in the home for a business or an organization 3 (20) I work outside of the home for a business or an organization 8 (53) I do not work 3 (20) Choose not to respond 0 Children Yes 7 (50) No 7 (50) Choose not to respond 0 If yes, ages of children 2, 16, 16, 22, 22, 26, 30, 31, 31, 34, 35, 36, 38, 38, 40, 40 Open in a new tab Obesity was defined in this investigation as a self-reported BMI ≥ 30. It was conceptualized as a major global public health crisis, with a multitude of physical, psychological, and social ramifications. ACEs were defined as per the original ACES scale (Felitti et al., 1998 ; Nagy et al., 2019 ). All study participants were advised that because of the sensitive nature of the issues that would be discussed in the interview, they might experience sadness or feel stress. They were informed that if this happened, they could stop the interview at any time or choose not to answer a question (Merrill & Grassley, 2008 ; NYU Langone Health, n.d. ). The participants were provided a list of local and national hotline phone numbers and mental health services so that they could debrief and/or obtain appropriate counselling resources if needed after the interview (CDC, 2009 ; Dahlberg et al., 2008 ). Each participant was given an honorarium of a $50 Amazon electronic gift card for completing the interview. A total of 14 women between the ages of 18 and 64 met the inclusion criteria and agreed to participate in the study. Data collection Semi-structured, in-depth interviews with 14 participants were conducted to discover how the phenomenon of co-occurring obesity and ACEs presented itself in women's experiences. Although in-person interviewing most readily facilitates the full potential of the RLR approach, data collection was completed during the COVID-19 pandemic when there were restrictions on in-person research. Hence, Zoom videoconferencing (Zoom Video Communications, Inc., 2021 ) was determined to be the most appropriate data collection modality. The interviews were audio and video recorded and professionally transcribed (Landmark Associates & Inc, 2025 ). Interviews lasted from 31 to 75 min ( M = 55 min). The intent of the interview process was to reveal new meanings of the phenomenon. The investigation focused on how adult women with co-occurring obesity and ACEs lived, related to, understood, acted upon, and defined this phenomenon. Two RLR interviewing sequences were utilized. These sequences are defined by question type and intent: (a) directing questions, and (b) following up questions. Each interview began with a broad, open, directing question such as “tell me what it is like to live with obesity and ACEs.” The intent of this type of opening approach was to help the participants feel safe and to become comfortable speaking about their lived experiences. The interview then proceeded with focused questions based on what each participant revealed through the directing questions. Following up questions were then employed as more description or illumination was needed to comprehend the phenomenon and capture new meanings. Directing and following up sequences were interwoven throughout the interview, as new areas of attention and focus emerged (Dahlberg et al., 2008 ). Data analysis Data analysis focused on how the phenomenon reveals itself and the critical meanings of co-occurring obesity and ACEs in adult women. The goal was to understand the data as they were presented and as they revealed the phenomenon. Particular meanings of the phenomenon were discerned; this included both “lived, contextual nuances” and meanings that are universal, and “more essential, abstract, or general” (Dahlberg & Dahlberg, 2019 , p. 4). The relationships among meanings and meaning variations were examined, and data on understandings of the phenomenon as the participants experienced them in their lifeworld were explored and evaluated. This information was then utilized to probe “how it [the phenomenon] is and shows itself” and “how it is meaningful” (Dahlberg & Dahlberg, 2019 , pp. 3–5). The analysis is neither descriptive nor interpretive. It instead comprises a third way, proposed by Dahlberg & Dahlberg, ( 2019 ), in which the philosophical idea of inseparability—which recognizes that individuals' experience is intermingled with the world, does not spring out of an objective world, and is not created by a subject, but instead “results from a subjective involvement in a world that is already meaningful” (Dahlberg & Dahlberg, 2019 , p. 3)—guides the structure and form of the analysis. The whole-parts-whole tripartite approach was utilized for the analysis. This process requires moving from the text of interview notes (the primary whole) to data analysis (parts) to the meaning structure of the phenomenon (a new whole) (Dahlberg et al., 2008 ; Vagle, 2018 ). Each interview transcript was analyzed through a multi-step method (Vagle, 2018 ) which began with a holistic reading of a transcribed interview and simultaneous listening to the audio recording of the interview. This was followed by multiple line-by-line text readings in which reflective journal, memos, and other documents related to data collection to delve more into initial thoughts about the meanings—which connoted bridling. Individual meanings were identified; these were based on margin notes and markings. Additional readings were driven by the goal of looking for patterns of meanings across the data. Titles were assigned to the various patterns or related clusters of meanings that were identified. Additional patterns were revealed within and between these clusters as the Essential Meanings of the phenomenon began to show themselves. The data analysis included strong descriptions of the Essential Meanings of the phenomenon, along with additional constituent meanings—which denote individual differences of the phenomenon and its unique components—and participant quotes that describe the contextual meanings and nuances. Results Essential meanings Fundamentally, the meaning of the phenomenon of co-occurring obesity and adverse childhood experiences (ACEs) for adult women is about a boundaryless childhood existence, being in and out of control, and a lifelong trajectory of a vague or distorted sense of self. Such lived experience, from early childhood through the adult years, is often traumatic. It involves early rejection, pain, parental ire, abuse, neglect, and at times cruelty from other family members/others outside the home. The phenomenon means struggling with feelings of not being safe, cared for, or listened to. It is founded in family dysfunction, violation, humiliation, and objectification. The phenomenon denotes that to survive the overwhelming breach of body and psyche associated with ACEs, food is used for reasons other than physiological nourishment, such as for soothing when faced with fear, disassociating from physical or emotional pain, or expressing anger or rage. The phenomenon of co-occurring obesity and ACEs exposes the intense focus by parents and caregivers on projecting the ideal childhood and young adult body shape onto their children from a very early age; it speaks to the inability for those impacted to stave off the negative impact of others' routine inspection, scrutiny, and rejection experienced by not measuring up. Obesity is a response to existential suffering, suffering that includes ACEs. Constituent meanings Six intertwined constituent meanings further elucidate the phenomenon: (a) obesity as an existential response to ACEs; (b) a chaotic, abusive childhood with parents and other caregivers who neglected their parental duties; (c) indoctrination into the world of food misuse, weight concerns, and body focus; (d) the critical gaze of others and its impact on the self; (e) the burden of obesity and other persistent health conditions; and (f) adult perspectives on surviving the challenges of their lives. Obesity as an existential response to ACEs . The women became preoccupied with their fluctuating body size as children and young adults, often subjected to strict rules about food consumption, physical appearance, and weight loss or gain set for them by parents, caregivers, and other authority figures in their lives. They often felt a need to transform their physical selves and alter their emotional responses to meet others' demands. One participant described this primary recollection: ...it's always been something at the forefront of my life experience...one of my earliest memories are family members concerned about my weight, and either like very clearly saying things or showing things...like articles or clippings...[it] definitely has had a large impact on my life ( Participant #18, age 25–34 ). Starting in childhood or adolescence, the girls experienced sexualization, exploitation, and a sense that their bodies were foreign and sources of shame and humiliation. The girls internalized the objectification and diminishment by others. A disunification and separation between self and body occurred, accompanied by an altered sense of worth. The struggle with their obese bodies was something fixed; a buffer of sorts to an existence that was filled with flux and upheaval from living with ACEs. A chaotic, abusive existence with caregivers who neglected their parental duties. The women in this study recounted that they were often physically, sexually, or emotionally abused; they suffered from emotional and physical neglect and witnessed domestic violence. Many lived with parents who struggled with substance use disorders and/or mental illness. In this investigation, it was revealed that 79% of the participants reported emotional abuse, 64% experienced sexual abuse, 71% revealed a history of emotional neglect, 21% witnessed domestic violence, 64% lived with someone who abused drugs or alcohol, and 71% lived with someone who was depressed, mentally ill, or attempted suicide. Half of the women came from divorced families, and a third suffered physical neglect and/or physical abuse (see Table II ). One participant described her family life as “a mess”: Table II. Adverse childhood experiences (ACEs). ACEs category Participants ( N = 14) Number (%) Emotional abuse Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? Yes: 11 (79) No: 3 (21) Physical abuse Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Yes: 5 (36) No: 9 (64) Sexual abuse Did an adult person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? Yes: 9 (64) No: 5 (36) Emotional neglect Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family did not look out for each other, feel close to each other, or support each other? Yes: 10 (71) No: 4 (29) Physical neglect Did you often or very often feel that … You did not have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes: 4 (29) No: 10 (71) Were your parents ever separated or divorced? Yes: 7 (50) No: 7 (50) Witnessed domestic violence Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit for at least a few minutes or threatened with a gun or knife? Yes: 3 (21) No: 11 (79) Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes: 9 (64) No: 5 (36) Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes: 10 (71) No: 4 (29) Did a household member go to prison? Yes: 0 No: 14 (100) Open in a new tab My dad was an alcoholic...a real bastard...he would just pick on us, including my mother…she was like one of the kids because she was mentally ill…he was always afraid that my mother was cheating on him…he would…beat her up...it was pathetic because she was…completely defenseless...[and] she was schizophrenic ( Participant #22, age 50–64 ). The girls experienced a sense of powerlessness. They never knew when one parent would explode into a violent episode. At times, both parents were complicit in the wrongdoings. The mother would stoke the father's anger, and the father would enact the physical harms. According to one participant: ...he would come home drunk, and my mom would be pissed about something...you could be sound asleep...he would get you out of bed, and just start whipping you with a leather belt...I would have to wear jeans in the summer because...if I went to school with the black...marks on the back of my legs...my dad would've been arrested, and I would've been in CPS [Child Protective Services] ( Participant #40, age 35–49 ). Upheaval, discord, and rejection were interwoven into their lives. According to one participant: “It was almost like that generational trauma that was kind of passed down. It's...the...thing that nobody talks about...my mom's depression was...always...overarching” (Participant #17, age 25–34) . Another study subject from a divorced home described how as a young girl, she was abandoned by her mother. As the participant explained, “...she determined that [the custody arrangement] wasn't good enough for her, so she moved out of the state...she left and didn't tell me” ( Participant #18, age 25–34 ). Other caregivers exhibited bizarre behaviors. The same participant depicted her stepfather as “high all the time...he thought he could heal people from across the room, and that he had higher powers” ( Participant #18, age 25–34) . Another woman told of her stepfather frequently verbally abusing her at the dinner table. “We'd talk about flying…but he'd always go like this, ‘goodbye,’ and make it like I was gonna [ sic ] go crash in a plane.” When she asked her mother to intervene, “my mom would get mad at me and say I was being rude ” ( Participant #55, age 50–64 ). Some of the girls were left on their own or allowed to be in unsupervised situations with uncles, cousins, or grandfathers. This led to repeated episodes of childhood sexual abuse and sexual exploitation. According to one participant (who was between the ages of 7 and 9 at the time of the abuse): “My mom would have him [her uncle] at our house, and he would mess around with me...sexually…and he would…assault me” ( Participant #40, age 35–49 ). If the girls tried to report the abuse, they might be ignored or told to ignore the offender. One woman described an incident as a young teenager when a family friend who “creeped her out” propositioned her for sex within earshot of her parents. “My father's friend…was a drunk…he told me he wanted to have sex with me...when I told my parents, they said...he would never say that…[and] I was lying because I didn't like him” ( Participant #57, age 50–64 ). Ind octrination into the world of food misuse, weight concerns, and body focus . Problems with food and weight began at an early age, and these concerns, like ACEs, were part of the girls most basic of recollections. According to one participant, “As long as I can remember, my mom always told me ‘you’re so fat’...[and] need to lose weight” ( Participant #11, age 35–49 ). Unable to meet a rigid body ideal, some women described being pressured to follow strict weight loss diets. The same participant described her awkwardness and chagrin at age nine when forced by her mother to attend commercial weight loss meetings: “I was horribly embarrassed, not so much about the weight, ‘cause I was still kind of almost too young to really understand that whole piece of it’, but...I was clearly the only child there” ( Participant #11, age 35–49 ). Parental attitudes and behaviors about food could also be used as a means to instill fear about the girl's body sizeor as a ploy to boost their mood during instances of familial strife. One woman recounted that to stop her father's repeated bouts of verbal and physical abuse the family enticed him with food. She explained: “Food...was very protective for us…it was always a way to guarantee that we could change the energy...it was a way to bring harmony back into the situation” ( Participant #45, age 50–64 ). Another participant described how food was often used by her father as a means to punish and abandon her: Whenever I wasn't grateful, he would lock me out of his room. I would have severe panic attacks and tantrums…I was around nine. And he would be like ‘I'm not your dad anymore. I don't love you’ and…literally close a door on me. And this was all because I wasn't happy that he was…boiling corn for dinner ( Participant #16, age 18–24 ). For some of the women, food was seen as a means of comfort when faced with loneliness, fear, or rejection. Food was a way to “stuff down” uncomfortable feelings about being neglected or insignificant. As one participant explained: “I would be proud of something, and nobody was interested…to find comfort, I would just go and eat...[at] five, six, seven years old...until I felt super full...eat extra at dinner...and then I would want dessert...then a snack after that” ( Participant #17, age 25–34 ). Another woman explained that as an overweight child she was refused entrance into dance class, when slimmer girls were readily accepted: “The woman told my mother that I was just too fat for the ballet…she's like, ‘Look at all the other girls, look how nice and thin they are’...I kinda [ sic ] got used to being told that I was too fat for stuff” ( Participant #24, age 50–64 ). The critical gaze of others and its impact on the self . Starting in early childhood the girls often dealt with the critical, disparaging gaze of others regarding their unacceptable girth, and inability to conform to cultural ideals of size and beauty. To manage this, participants shapeshifted—desperately wanting to measure up to others' expectations and to transform themselves into something that they were not—wishing for a perfect body or appearance, constantly struggling to “fix” their figure with dieting and exercise. They perceived themselves as non-conforming and that their existence was problematic. They developed a harsh inner voice which has stayed with them into adulthood. Participants as children also shapeshifted to avoid familial violence. They created stories that if they were only thinner, or listened better, or did exactly what their parents wanted, they would not get beaten by their father or ignored by their mother, or they could avoid sexual abuse by their uncle or cousin. One participant explained that she created a guise as the “good child” to avoid causing conflict in her family: There was a lot of fighting…my dad was...quite often an instigator...it created something for me where I was kind of always trying to avoid being in trouble for anything and develop this type of persona that I'm not like the one that needs to be worried about because I am doing everything right ( Participant #65, age 25–34) . In response to others' critical, demeaning attitudes and words, the girls learn to despise themselves. They are subjected to ongoing body objectification and suffer with feelings of intense shame and humiliation. As one participant describes: “...being in this body is horrific...I try not to look at myself in the mirror if I'm walking my dog...[by] a...window and I see myself, I'm disgusted. I detest being in this body” (Participant #10, age 50–64) . This self-disdain also becomes a means to self-blame about ACEs. According to one woman: “...no one took accountability [for the abuse]...there needed to be an equation as to why those things equaled out the way...they did...no one was filling that equation...then it had to be my fault” (Participant #16, age 18–24) . And as another woman described: I always had low self-esteem and a lot of self-loathing...mostly from the incest, mostly from the sexual abuse, that caused me a lot of self-hate because...I was torturing myself with it....my dad was a real bastard, and [he] ruined my childhood...my childhood was already fucked up...he just put the nail in the coffin (Participant #22, age 50–64) . The objectification and violation that the women have suffered from living with obesity and ACEs can negatively impact their sense of agency; it can also mean a cleavage between their body and their identity. They may continue to perceive themselves as fractured or anomalous. As described by one participant: “I used to think that they forgot a piece. Like they forgot the steering wheel on a car…and I was missing…directions to life that everybody else had. I thought the whole world was normal [and I was not]” (Participant #57, age 50–64) . Burdened with obesity and other persistent health conditions. Some participants face the challenge of living with both obesity and other chronic health disorders; a number of whom understand the intertwined nature of their obesity and their other health conditions, and the dual challenges of being obese and living with chronic health disorders. Stated one woman: “I...have two medical conditions that make it easier to gain weight...polycystic ovarian syndrome [PCOS] and hypothyroidism. It took a while to get diagnosed with the PCOS...while I was going through...the workup...I still just have gained and gained and gained” ( Participant #17, age 25–34 ). Other participants may not want to manage their obesity or may only do so in an intermittent manner. Their focus on treatment and adherence for other chronic health conditions may understandably take precedence. According to one participant with myalgic encephalomyelitis/chronic fatigue syndrome (ME-CFS): [Managing my weight]—that's honestly not a concern from any of my doctors or myself. It's more managing the chronic illness...the inflammation markers in my body are higher, which [are] common in CFS as well as...obesity...I have so many other health factors that are playing a role...which could have an initial root in...constant stress, lack of stability, and none of these other things that I had as a child ( Participant #51, age 25–34 ). Some participants described that when they developed a chronic health disorder it became a galvanizing force to manage their obesity. Stated one woman: “It really is a wakeup call for me. Like that importance of getting this [pre-diabetes] under control. Because my weight has never really caused me any serious health issues...it really compels me to take it seriously now” ( Participant #45, age 50–64 ). Adult perspectives on surviving the challenges of their lives . Participants with co-occurring obesity and ACEs developed various strategies to survive the multiple challenges of their lives. One participant described her tactic: “I created my own reality because I had nothing to teach me differently...it didn't occur to me...that it was criminal...it was incest...it was abusive...that...it wasn't normal. If it's all you know, it's all you know” (Participant #57, age 50–64) . Exposure to other families and removing themselves from their abusive situations at home offered an escape to their tragic lives. According to one woman: “I didn't realize there was something else until...college...I was isolated my entire [life]...I didn't interact with my family unless they made me...because neither one of my parents were safe. There was no bonding to them” ( Participant #51, age 25–34 ). Another participant woman described a similar situation: I got a really good friend in sixth grade who became my best friend...and I would go to her house every weekend and stay gone literally...not being face-to-face with all of the reality of it all, all the time, was how I handled the situation ( Participant #40, age 35–49 ). Other participants also knew early on that things were dreadfully amiss, and as adults, they describe their insights regarding ACEs and their childhood coping mechanisms that centred around food. One woman explained: I think that because I felt so tortured growing up...and knew that it was not normal and knew that it was wrong...I think that I became...especially after my friend died, I became self-indulgent...it's like ‘well, I deserve this bucket of ice cream because of everything that I've suffered’...it's like a part of me didn't care enough about myself, I guess (Participant #22, age 50–64) . Recounted another participant: “ Am I eating this, am I choosing this for comfort, or am I feeling something else...it's kind of also getting to the bottom of my feelings because part of the ACEs that I dealt with was…‘don't have feelings’” ( Participant #17, age 25–34 ). Some participants responded to events in their early lives by thinking of themselves as atypical or abnormal. One woman recounted that she continues to feel this way. She told of her excitement about being taken out to eat by her grandfather, and then her disappointment to discover that instead of congratulating her on a recent academic accomplishment, he instead chose to express his distress about her body size and eating habits: It was...definitely a feeling of like something's wrong with me, like I'm not good enough...like I'm never going to be good enough unless I lose weight...or I don't look the way that I do...this has continued in different ways throughout my life (Participant #18, age 25–34) . This feeling of being different because of co-occurring obesity and ACEs prevents some women from beginning or continuing close, intimate relationships. One participant described how her body size, combined with the memories of repeated childhood sexual abuse that she suffered at the hands of her uncle negatively impact her current intimate relations with her husband: “It's really about my own insecurities...I kind of was that way even when I weighed 100 pounds. Because my uncle had done what he had done” ( Participant #40, age 35–49 ). Another woman highlights the struggles that she faces when trying to date online. She wants to have a relationship, and longs to find a partner, but finds it very difficult because she feels she is hindered by her obesity and the legacy of her past abuse: I'm trying to not let depression and loneliness and whatever else comes my way be the reason that I eat...I honestly believe that it's a huge part of why I'm very unsuccessful...[with] online dating. And because I don't want to be alone, I'm having to deal with something at 59 that I shoulda [sic] dealt with at 9, or 10, or 11, or 25, or whatever (Participant #57, age 50–64) . This capitulation to being trapped in their bodies and living with the consequences of ACEs often means being hindered from moving toward self-actualization. One participant described her efforts to remain inobtrusive in adulthood because she did not want to contend with her size and the childhood trauma that she endured: I just...stay in the background, so that way I don't have to deal with it. And I think that's just my learned behavior...we adapt to it from how we're brought up...And that was just my way of coping with it (Participant #24, age 50–64) . Thankful to be alive and have endured. A number of women also provided descriptions of the “advantages” of suffering from childhood abuse and living with obesity. These include maintaining a pragmatic world view, surviving the COVID-19 pandemic when others were besieged, and managing other types of misfortune. There is a sense of being thankful that they are alive and have endured. One participant described how her difficult childhood and youth allowed her to develop ways of managing during the pandemic that others without similar life hardships would not have acquired: I think that I was better prepared for it [COVID]...than a lot of people...I feel like I kind of had it rough when I was a kid...I'm not saying it was...a good thing, but I figured it out. I learned coping strategies...it was certainly not the worst thing that ever happened to me (Participant #11, age 35–49) . Another woman believed that her girth helped her persevere through COVID while others around her succumbed and became ill: While everybody else [was] going down with COVID I didn't...all that fat saved me from bein' with you...I stayed well...and I was always the one who did all the extra stuff because...they were sick. So, I told 'em...'All that extra fat come in handy somewhere along the way’ (Participant #24, age 50–64) . Other participants expounded upon the sense of strength and fortitude that they derived from living with ACEs and obesity. Asked one woman, “have you ever heard the expression, whatever doesn't kill you makes ya’ stronger? Okay. Well, it didn't kill me” (Participant #57, age 50–64) . Therapy as a healing force. Finally, a number of participants expressed a desire to 1) understand the implications of their violent and chaotic childhoods more fully, 2) learn more about the relationship that they have with food and their bodies, and 3) examine the damage that has been wreaked on their past and current lives by engaging in ongoing psychotherapy. There are participants who have found psychotherapy and counselling to be a positive experience, which has led to enhanced insight and awareness. According to one woman, “I had all of the material things, but...a lot of the emotional support was lacking...my therapist...helped me to understand that and...work through it ( Participant #17, age 25–34 ). Others found the thought of entering therapy initially daunting and frightening, but persevered and found much insight into their past traumas. As one woman stated: I have sought mental health therapy...I thought it was...a taboo thing...I kinda had that in the back of my mind when I made that first attempt and...stopped showing up...this time around I've...tried to...surrender to the process...it's allowed me to open up about certain things that I just have refused to talk about that probably or definitely...have been affecting...everyday life...a lot of things...swirl around and circle back to my experience growing up (Participant #65, age 25–34) . Other participants as well describe how through the therapeutic process they are able to make the connection about co-occurring obesity and ACEs and the impact that it had on various aspects of their lives. One woman described her struggles to quit smoking and lose weight as “outward” behaviors that she had previously thought would alter and improve her negative sense of self; her treatment provided another type of understanding. “I learned from many years in therapy that my inside things are all related to childhood. They're all related to me feeling less than, not being worthy, not being worthy enough to have a life worth living” ( Participant #10, age 50–64 ). Another participant decided to discard past ways of disparaging herself and her body and embrace self-compassion instead: “...right now, I'm...on a journey of accepting my body...I'm never gonna be 120 pounds. It's more of, like, what do I have...and what can I make of it...I guess I'm just tryin’ to be kinder to myself now” ( Participant #16, age 18–24 ). Discussion To this researcher's knowledge, as of December 2025, this is the first study of its kind to address how the phenomenon of co-occurring obesity and ACEs shows itself among adult women and to treat these co-existing states of being and their implications as actual complex problems. Rich, descriptive evidence from the study illustrated how the three essential and six constituent meanings defined and expanded upon the understanding of the meaning of co-occurring obesity and ACEs for adult women. Understanding that obesity is an existential response to ACEs is important for several reasons. First, it can help dispel the myth that obesity is a disorder of personal failure or lack of self-control. Second, it connotes a serious need for children and adolescents who were repeatedly abused and neglected and faced ongoing familial dysfunction to find a source of sustenance, comfort, and protection. Third, though obesity often served an important function for self-regulation of painful effects of ACEs for participants, especially in regard to interpersonal relationships and ways of being in the world, it came at the cost of stigmatization, low self-esteem, loss of control, and for some, co-morbid physical and mental health conditions. Fourth, this comprehension provides new opportunities for developing comprehensive care modalities to enhance health and well-being that address and integrate ACEs trauma, obesity, and their important interrelatedness. In addition, conceptualizing obesity as an existential response to ACEs can allow researchers to further probe the associations, connections, or biological pathways between ACEs and obesity as found in previous quantitative investigations of this topic (Day et al., 2009 , 2010 ; Felitti et al., 1998 ; Felitti, 2019 ; Hughes et al., 2017 ; Lissau & Sorensen, 1994 ; Mahmood et al., 2023 ; Mersky et al., 2013 ; Wiss & Brewerton, 2020 ). Scholars studying ACEs suggest that the traditional 10 ACE categories, along with individual influences on obesity—such as social and environmental conditions—interact with genetic factors to produce a range of different phenotypic outcomes. In lieu of focusing on obesity as one disease, or ‘the’ disease to be treated, therefore, it is essential to acknowledge “that multiple phenotypical expressions of obesity necessitate an expanded understanding of this confluence of contributing factors” (Jared, 2026 , p. 36). Potential findings from future investigations in this area could have major implications on enhancing health outcomes for those living with obesity and ACEs. For some participants in this study, obesity became, among other things, a way to avoid initiating intimate relationships, or a way to stay distanced from current partners. This is similar to previous studies that revealed obesity was a means of protection from the threat of potential or actual abuse (Felitti, 1993 ; Gustafson & Sarwer, 2004 ; King et al., 1996 ) or with the desire to remain invisible to prevent unwanted sexual attention or predation (Felitti et al., 2010 ; Felitti, 1991 , 1993 ; Gustafson & Sarwer, 2004 ; King et al., 1996 ). The current study acknowledges and builds upon the results of previous investigations that demonstrated how early maltreatment effects can last a lifetime, and that cumulative exposure to ACEs puts one at risk for toxic and debilitating physical, emotional, and psychological health repercussions through adulthood (Cuevas et al., 2019 ; Danese & Tan, 2013 Hemmingsson et al., 2014 ; Hughes et al., 2017 ; Irish et al., 2010 ; Midei & Matthews, 2011 ; Palmisano et al., 2018 ; Paras et al., 2009 ; Wang et al., 2015 ). The results of this study highlight that the lifelong repercussions of co-occurring obesity and ACEs can be intractable and negatively color one's sense of self, sense of well-being, and sense of belonging—to another person or persons in relationships, or sense of belonging in the world. In addition, our study adds to findings from previous qualitative studies on the lived experience of obesity that used phenomenological lifeworld research to examine the existential experience of obesity as it is associated with (a) well-being (Haga et al., 2019a ); (b) objectification, alienation, and longing to feel normal (Ueland et al., 2020 ); and (c) the impact of stunting one's life trajectory (Haga et al., 2019b ). Our study demonstrated that for many women, living with both obesity and ACEs magnified the sense of objectification felt from others and allowed the women to turn this sense of objectification upon themselves, leading to dire consequences. These consequences in some cases prevented them from successfully navigating their life's responsibilities and relationships. Our study also highlighted not only that the women often felt alienated from others but also cut off from their sense of self and their bodies; they often see themselves as abnormal or aberrant. A number of the women in this study accepted personal and societal verdicts and weaponized them against themselves, also mirroring what prior investigations have revealed (Amy et al., 2006 ; Carryer, 2001 ; Ogden & Clementi, 2010 ; Puhl & Heuer, 2010 ; Schaefer & Thompson, 2018 ; Wang et al., 2004 ). Participants found ways to criticize themselves before someone else did, using pathological accommodation (Brandchaft, 2007 ) in order to gain a sense of control. This study, in addition, elucidated that pathological accommodation also became a means to identify with the aggressor/perpetrator, internalize and perpetuate these negative behaviours within themselves, and as a way to defend against their aggressor's hostile criticism and stigma. Previous research has revealed that continuous negative messages from family, peers, society, and the media about weight concerns and body focus can potentially be damaging to obese persons' mental health, particularly if internalized by the targeted individual (Choi et al., 2016 ; Randall-Arell & Utley, 2014 ; Ueland et al., 2019 ). Prior research has also illuminated the confluence of familial factors that shape a child's response to abuse and neglect by modelling multiple categories of abuse and their potential social, biological, and functional ramifications (Committee on Child Maltreatment Research et al., 2014 ). These findings elucidate that the obesity-ACEs connection can be bi-directional; investigations have revealed that weight stigma and its aftermath/sequela can lead to adverse psychological and physiological outcomes in overweight and obese adults (Wu & Berry, 2018 ) and children (Sikorski et al., 2015 ). In addition, the sense of being discriminated against because of one's larger weight and size has been found to be associated with subsequent negative psychiatric outcomes (Hatzenbuehler et al., 2009 ). The current investigation delineated clearly that the girls internalized the negative attitudes forced upon them, beginning at a very early age, by their parents and other caregivers. As women, they spoke of how entrenched and long-lasting these destructive feelings were. The results highlighted the complexity of co-occurring obesity and ACEs—the increased shame, stigma, and inability to overcome the deleterious effects of being abused, neglected, and subjected to ongoing family dysfunction compounded the effects on the women's mental, physical, and emotional health. Other individuals made it difficult for the girls to disclose abuse, neglect, and family dysfunction. These findings corroborate prior research about the hidden nature of ACEs and that individuals rarely disclose their history of these exposures. This can give rise to misperceptions about the problem and impedes those who need help from getting it (Courtois, 2014 ; Finkelhor, 1994 ; Herman, 1997 ; Weinreb et al, 2010 ). Gemara and Katz ( 2023 ) reported on disclosure of childhood sexual abuse and focused on difficult challenges that the participants faced with (a) the revelation of the violence and (b) their perceptions of the recipient of the information. Unspoken secrecy “pacts” revealed in the current study often prevented the girls from divulging their abuse. Having their feelings and concerns ignored as children hindered the ability of some to form healthy adult attachments built on trust, consistency, and mutual respect. Transgenerational transmission of trauma and its psychological, social, psychobiological, and epigenetic effects appeared to be at play in a number of the girls' families. Previous research found that parenting stress, or “negative feelings related to the demands of parenting” (Crouch et al., 2019 , p. 186), living in poverty, and having a history of their own ACEs can impede effective, empathic parenting and can increase the chance that a person's offspring will also be exposed to childhood maltreatment and neglect (Ammerman et al., 2013 ; Ray et al., 2021 ). A number of the participants in our investigation identified the transgenerational destructive nature of their co-occurring obesity and ACEs and made known their intent to try to break this cycle in their own child-rearing practices through their ongoing investment in regular psychotherapy. The current study also substantiates and adds to findings from prior investigations that demonstrated how food and/or disordered eating patterns became a type of entrapment (Grant & Boersma, 2005 ; Ueland et al., 2019 ). Food restriction, food rewarding, and food consoling during highly charged emotional situations were a part of many participants' earliest memories. These behaviours and attitudes were often in response to adult insistence and control, were a form of emotional and verbal abuse, and have been termed by other authors as food misuse, food abuse, food neglect, or “weaponization of food” (Guiney, 2022 , para 3; Mole et al., 2015; Vaughn et al., 2016 ). Coercive and emotional feeding practices—similar to what the current study participants experienced—have been found to be counterproductive and foster problematic appetite regulation and decrease one's ability to make healthy food choices (Daniels, 2019 ; Polivy, 1996 ). This study's results provided even more detail on “double binding” behaviours that resulted in conflicting and painful feelings for the participants, and which often became part of their existential struggle with food and their bodies. This investigation highlighted that the women were subjected to weight bias and stigma in their interactions with healthcare providers. These findings echo those of previous qualitative studies (Merrill & Grassley, 2008 ; Ueland et al., 2020 ) and corroborate others that found that health care professionals would often concentrate solely on a person's obesity or body size and potentially or actually disregard other health issues that were more urgent (Carryer, 2001 ; Haga et al., 2019b ; Merrill & Grassley, 2008 ; Owen-Smith et al., 2014 ). Obesity for many individuals means the potential for a diminished quality of life and premature death (Centers for Disease Control & Prevention, 2022b ; National Institute of Health. National Institute of Diabetes et al., 2018a ). Our analysis showed that living with obesity and ACEs was also at times complicated by other chronic health disorders. This finding aligns with previous research that has demonstrated a link between childhood maltreatment, impaired psychological function, increased health risk behaviours, obesity, and other chronic health disorders (Felitti et al., 1998 ; van der Kolk, 2000 ). Another powerful finding that this investigation uncovered was how some participants were able to conceptualize their co-occurring obesity and ACEs in terms of the advantages that the adversity conferred. Seery ( 2011 ) describes this as a type of toughening and resilience that allows those who have faced hardships in the past to manage and overcome tense, challenging situations more readily in the present. Tedeschi & Calhoun ( 1996 ) term this resilience and resourcefulness “post-traumatic growth” to describe positive psychological changes that can occur in the aftermath of traumatic experiences. The results from our investigation provided an important understanding of the meaning of co-occurring obesity and ACEs that heretofore carried with it much negativity and pain. It demonstrated a “rise from the ashes” take on participants' lives that were marred by adversity, and a strength and perseverance for some that was very meaningful. Strengths and limitations The study had a number of strengths. The first strength is that we investigated co-occurring obesity and ACEs as a phenomenon, thereby giving voice to a population that is often misunderstood or maligned due to intractable stigma or lack of knowledge about the meaning of this intertwined relationship. The comprehensive data that we obtained from participants through deep, probing interviews about what living with obesity and ACEs means is critical; it provides more insight into exploring more extensive and holistic ways in which to provide inclusive, targeted healthcare to these individuals. The second strength is that we used RLR and the advantage that it provided as a robust foundation and structure that undergirded all aspects (design, methods, data gathering, and analysis) of the study. By utilizing RLR, we optimized the possibility of discovering novel meanings about co-occurring obesity and ACEs. A third strength was having four recruitment sources, which produced a larger sample size than originally projected and increased the diversity of the participant population. The fourth strength was the multiple confidentiality protections that were embedded in the study design and methods. There were also a number of limitations to this study. The first limitation was that in-person recruitment during 2021 yielded only one participant, and that participant failed to attend the interview. Recruitment efforts were therefore expanded through online media services, social media platforms, and two research registries. These virtual settings yielded the fourteen participants. The second limitation, which was associated with COVID-19 pandemic restrictions on in-person research, was that the impact of immediacy on the interviews was potentially hindered because of the need for virtual methods. The revised interview modality, however, had several potential advantages. Specifically, some individuals might have felt more free to reveal their feelings and experiences by phone or video conferencing than in person (Archibald et al., 2019 ; Drabble et al., 2016 ). The third limitation was related to the lack of diversity in the study sample in terms of race, ethnicity, and educational attainment. Nine (64%) of the women identified as White, four (29%) identified as African American, and one (7%) identified as more than one race. One woman identified as Hispanic. There were no American Indian or Alaska native, Asian, or Native Hawaiian or Pacific Islander participants; these additional demographic groups are also impacted by obesity and ACES (Mersky & Janczewski, 2018 ; National Institute of Health. National Institute of Diabetes et al., 2021 ). In addition, most of the women in the study sample had some higher education. Nearly 80% of the participants reported completing a college or master's degree. In contrast, as of 2022, 39% of women in the US reported having a college or graduate degree (United States Census Bureau, 2023 ). Hence, the study sample's demographics are not likely to be representative of the general population of women with co-occurring obesity and ACEs. The fourth limitation pertained to time allotted for participant interviews. Because of the complexity of the study subject matter and the in-depth manner in which participants were willing to share their experiences of co-occurring obesity and ACEs, 45–50 min was not always enough time to delve into and fully cover the multi-faceted topics that arose about the phenomenon. Additional research is needed to examine this phenomenon with longer-lasting interviews, and/or more than one interview per participant. The fifth limitation to the study is relevant to the number of ACEs reported by women versus men from an expanded global perspective. The current study only focused on this comparison in the USA, where women are more than 50% more likely to report four or more ACEs than are men (Felitti et al., 1998 ; Felitti, 2002 ; Merrick et al., 2018 , 2019 ; Waite & Ryan, 2019 ). It must be noted, however, that in other parts of the world, in countries such as the Kingdom of Saudi Arabia, in one large, cross-sectional study ( N = 10,156, women = 48% of the sample) men were more likely than women to report more than 4+ACEs (Almuneef et al., 2017 ). Another recent investigation from 2024 demonstrated that higher numbers of males between the ages of 18 and 24 (81.9%) versus females (72.1%) in Cote d'Ivoire, Kenya, Lesotho, Mozambique, and Namibia experienced at least one ACE (Brown et al., 2024 ). Future investigations should consider these differences in global ACEs reporting in order to address gender variations that may impact interventions to improve health and well-being in across the gender perspective. It is also important to recognize, however, that in patriarchal societies, women may fear repercussions of reporting sexual harassment or abuse or be forced to confront stigma that is reinforced by cultural beliefs and norms (Anwar et al., 2022 ; Hamid, 2021 ). The final limitation is that the study did not address questions of intersectionality impact of obesity and ACEs with gender identity and sexual preference. Sexual minority women (SMW) (individuals who identify as lesbian, bisexual, or other types of non-heterosexuals) are known to report a higher number of ACEs and have been exposed to all types of ACEs than are heterosexual women (Bochicchio et al., 2023 ; Giano et al., 2023 ). Other investigations have revealed that when compared to heterosexual women, SMW have higher rates of overweight and obesity (Azagba et al., 2019 ); transgender/gender diverse populations also demonstrate this pattern (Taormina & Iwamoto, 2023 ; Fornander et al., 2022 ). It is important that future studies in this area elicit information about gender identity and sexual preference in order to provide additional understanding of the meaning of co-occurring obesity and ACEs and to widen the scope of care interventions available to these diverse populations. Implications Practice implications The empirical results elucidated that many participants desired assistance with managing difficult aspects of their adult lives. They also wanted to understand their complex histories and physical and mental health challenges. Many sought help with these concerns through engaging in psychotherapy. Other options for therapeutic management of co-occurring obesity and ACEs could also include specific treatment such as (a) psychodynamic therapy; (b) compassion focused therapy; (c) body oriented, somatic, and mind-body therapies; (d) therapies to address the three essential meanings of the phenomenon as revealed in this study; and (e) comprehensive weight loss solutions that include a focus on mind, body, self, and enhancing health and well-being. In addition, current research into the connection between ACEs, substance use, poor health outcomes and treatment (Derefinko et al., 2019 ) could also inform and improve care for those with co-occurring obesity and ACEs. Research implications There are four major areas for future research that build on the findings from this study. They are: (a) incorporating essential meanings into the therapeutic process, (b) understanding the impact of psychotherapy, (c) determining targeted behavioural intervention efficacy, and (d) evaluation of the simultaneous treatment of obesity and ACEs in primary care settings. Investigating each of these topics has the potential to provide more knowledge and insight into increasing the overall health and well-being for women who struggle with co-occurring obesity and ACEs. The findings may lead to key information on what is necessary to bolster a person's self-worth and identity; and to find what it takes to heal from a trajectory of pain and rejection. Conclusion This study elucidated essential and constituent meanings that defined, bolstered, and expanded upon the understanding of the meaning of co-occurring obesity and ACEs for adult women. The study highlighted that the tether that binds certain women's negative self-regard to their obese bodies and their history of ACEs can be long-lasting and ever-present. Despite this, participants found ways to live their lives, to establish careers, and to achieve in academic pursuits, through community work, and by creating their own families and raising their children. Many have sought assistance with their challenges with co-occurring obesity and ACEs through psychotherapy. There are opportunities for healthcare professionals to expand their practice so as to assess for and concurrently treat a woman's obesity and ACEs. Further research in this area is needed that reflects diversity in race, ethnicity, age, socio-economic status, sexual orientation and gender identity, and other pertinent demographic factors. There is hope that additional investment in and access to therapies and interventions that address the specter of living with co-occurring obesity and ACEs can lead to self-actualization and the ability to establish a relationship with the world in a way that can be life affirming and satisfying. Acknowledgement This manuscript is developed from the first author's doctoral dissertation that was completed at [New York University, Rory Meyers College of Nursing, 2023] . We would like to express our deep appreciation to the participants for their willingness to share their experiences and for their desire to contribute to this work. We would like to thank Dr. Jared's dissertation research committee members Dr. Karin Dahlberg, Dr. Judith Haber, Dr. Susan Altman, along with Dr. Holly Lofton for their continued and enthusiastic support for this project. Dr. Jared would like to thank Dr. Mauricio Arcila-Mesa for his help with the design of study subject recruitment and enrolment REDCap forms, and the administrative staff at NYU Rory Meyers College of Nursing and NYU Langone Health for their assistance with recruitment, enrolment, and participant reimbursement processes. Funding Statement This work was supported by Jacqueline Fawcett Award in Nursing Science. Sigma Theta Tau International, Upsilon Chapter. Disclosure statement No potential conflict of interest was reported by the author(s). Data availability statement Data not available—participant consent. The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available. References Almuneef, M. , ElChoueiry, N. , Saleheen, H. N. , & Al-Eissa, M. (2017). 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