Psychosocial Experiences and Coping Strategies of Young Women with Obesity

Amna Shafique* and Rafia Rafique

Institute of Applied Psychology, University of the Punjab, Lahore, Pakistan

*Corresponding Author: [email protected]

Abstract

The current study aimed to explore the psychosocial experiences and challenges faced by young women with obesity and the type of coping strategies they use. Weight-based stigmatization is prevalent in Pakistan (Memon et al., 2019) and about 50% of the population is obese in Pakistan (Tanveer et al., 2022). In the age of technology and media, the prevalence of idealized body images has caused to internalize media representations and people’s views about obese women which are quite negative and they consider such women as incapable of doing anything (Kite et al., 2022). The study employed a qualitative research method. Semi-structured interviews were conducted using a sample of six young obese women. Interviews were analyzed using Interpretative Phenomenological Analysis which provides an in-depth and comprehensive viewpoint. A total of 33 sub-themes were extracted and five superordinate themes emerged from them. These themes include loss (self/social); psychological consequences (negative thoughts/negative emotions); concerns (physical/future); interpersonal challenges (family/ friends/ strangers), and coping strategies (adaptive/ maladaptive). The current study indicates that young women with obesity in Pakistan have various negative psychosocial experiences. The study highlights the need to introduce strategies focusing on enhancing adaptive coping among individuals experiencing stigma such as obese individuals. Additionally, it encourages community-based programs to provide awareness of and management solution for obesity to ensure well-being among these individuals.

Keywords: coping strategies, obesity, psychosocial experiences, young women

Introduction

Obesity is characterized as an excessive fat buildup that might harm one's health (World Health Organization [WHO], 2020). Individuals' body mass index (BMI) is used to categorize the level of obesity. Asian obese people are those whose BMI is 27.5 or higher (Bays et al., 2022). Obesity involves malfunctions of the adipose tissue, the endocrine system, and the central nervous system and goes beyond the passive accumulation of excessive weight. Diet and lifestyle choices, socioeconomic status, exposure to chemicals that disrupt the endocrine system, drugs that cause weight gain, infections, and alterations in the microbiome are external factors that may impact obesity (Schwartz et al., 2017).

Restraint theory, disinhibition, and boundary model are the three primary psychological theories that account for obesity. According to cognitive theory of restraint, attempts at restrained eating paradoxically lead towards obesity (Verstuyf et al., 2012). Disinhibition or inability to have self-control while eating results in binge eating or overeating. It may be influenced by various social or environmental triggers (Hays & Roberts, 2008). According to the boundary model, people who eat in restraint need more food to feel contended because they are less sensitive to satiety cues. They overeat to the point where they surpass both their biological and self-imposed satiety boundaries which causes them to put on weight (Stroebe, 2022).

 Stigmatization, based on weight, is the primary psychosocial factor influencing the lives of obese women. Such women are stigmatized heavily in both European and Asian societies. Weight-based stigma is also prevalent in Pakistan, damaging individuals' physical and emotional well-being and community (prejudice). Weight stigma is defined as unfavorable patterns of conduct towards obese persons due to their size or weight (Cuzzolaro & Fassino, 2018).

Body image plays a pivotal role in psychosocial experiences of young women with obesity. The prevailing societal preference for skinniness as an ideal imposes a considerable burden on these individuals, fostering the feelings of marginalization and contributing to a strained relationship with their bodies. The pervasive influence of negative body image permeates various facets of their lives, extending its impact to interpersonal relationships, participation in social activities, and the overall quality of life. This complex interplay between societal expectations and personal perceptions underscores profound challenges that young women with obesity encounter in navigating their psychosocial well-being (Aparicio-Martinez et al., 2019).

Obese people experience three types of stigmatizations. These stigmatizations include direct stigmatization which involves experiencing public shame; environmental stigmatization, such as being seated in a public place or a communal area; and indirect stigmatization which may include being pointed out or stared at in public settings (Cuzzolaro & Fassino, 2018). Additionally, Hayward et al. (2018) outlined the process between weight-stigmatized people's coping strategies and their stigma experience. Greater levels of self-stigma were associated with repeated interactions with weight stigma and this association predicts the coping strategies that people would employ in response to these encounters. The coping mechanisms employed in reaction to weight stigma range from maladaptive coping mechanisms, such as self-blame and increased emotional eating, to adaptive coping mechanisms, such as positive self-talk and seeking social support. Disengagement coping and less frequent use of reappraisal coping, both of which were associated with weight stigma, were anticipated to occur more frequently (Wadden & Bray, 2018). 

Previous studies have shown that obese women view themselves as negative and they also devalue themselves due to their weight and extreme amount of weight stigmatization in their daily lives (Poynter, 2020). They face distinct types of stigmas, such as they get abused while using public transport, environmental stigma, and indirect stigma, for instance, people stare at contents of their supermarket trolley (Lewis et al., 2011). Weight-based stigma negatively influences the individual’s perceived self-identity as they call them ugly (Rafeh & Hanif, 2020).

People with obesity experience physical discomfort as they do not eat anything outside their homes due to the fear of comments or being teased. If they eat in front of other people, they are called as overweight and that they need to control their eating pattern which negatively affects their health as they try not to eat anything when they are outside their homes (Langford et al., 2022).

In Pakistan, women are increasingly pressurized to have an ideal physique. Internalization of these body ideals portrayed by media negatively influences the psychological health of women (Khan et al., 2021). Weight stigmatization experienced by these obese women makes them socially uncomfortable and they become extremely self-conscious or insecure regarding their appearance. Obese women tend to experience weight stigma to an extent which makes them mentally uncomfortable, they feel being left-out, teased, or bullied about their weight wherever they go. However, according to some people, their experience went far beyond discomfort and unhappiness into something they described as depression and anxiety (Farrell et al., 2021).

Obese women have to deal with hurtful remarks, presumptions, rejection from society, unwanted attention, and bullying. Strangers, instructors, coworkers, medical professionals, healthcare workers, their partners, family members, and friends are the people who make these remarks. Healthcare providers sometimes stigmatize obese individuals by presuming that, simply due to their health, they suffer from certain illnesses or other ailments. Obese people frequently experience discrimination in the form of stares and critical looks from others (Gerend et al., 2022).

Obesity may also impact women at their workplace and girls in schools. Research has indicated a possible relationship between academic achievement and weight which could have consequences for employment prospects. Students facing obesity issues may experience prejudice in their classrooms which could undermine their self-esteem and hinder their academic progress (Branigan, 2017). Weight-based discrimination may impede job advancement and limit prospects for both financial and personal growth at workplace (Giel et al., 2010).

Physical aspects of the environment, such as small seating or chairs with fixed armrests or sides, may have a significant impact on the activities of obese people. Additionally, there are limited clothing options that fit obese people well and plus-sized clothing with higher body weight comes at a higher cost. Individuals encounter uncomfortable situations while using medical devices (such as blood pressure monitors, crutches, stretchers, and scanners) that aren't meant for those who are obese (Randall-Arell & Utley, 2014).

Previous studies show that women facing obesity issues use different types of strategies to cope with their condition. They feel it an individual responsibility to lose weight and try extreme level of dieting to do so (Thomas et al., 2008). Social acceptance and invisibility are both survival strategies employed by obese students. Individuals who face bullying due to their over-weight often adopt certain strategies to expand their social circle or cultivate friendships. This serves as a defense mechanism for them when they are bullied as their friends come to their defense. Alternatively, having a wide network of friends may discourage potential bullies. Consequently, social circle enhances an individual’s social acceptance (Langford et al., 2022).

To avoid negative experiences, some obese people use the strategy of being invisible. They try to skip their classes or rarely show any participation. Moreover, they do not answer the questions of their teachers and they are also reluctant to seek help from teachers. The maladaptive coping strategies used by obese people may have negative impact on their learning through reduced participation and concentration in classes or how teachers and fellows view them (Langford et al., 2022).

Rationale

In Asian countries, obese women often experience weight-based stigma. It is the most deeply rooted stigma of our society due to sociocultural ideals of a thin body (Munir & Dawood, 2021). Both implicit and explicit instances of bullying, prejudice, and stereotypes about fat women have been documented (Fruh et al., 2021). Many unmarried women are rejected due to their weight since these women are often portrayed as physically less attractive (Blodorn et al., 2016). In the era of technology and media, the increased portrayal of idealized body images has led to internalization of media images and self-devaluation by obese women (Janjua et al., 2022). By exploring the underlying factors of weight stigma and coping strategies used by obese individuals, programs can be developed to encourage the use of adaptive coping strategies among individuals who have to endure stigma as a result of bodily changes due to weight gain.  However, scientific literature is rarely available on the subject of experienced weight stigmatization specifically within Pakistani culture. Therefore, the current study added to the empirical data by exploring the factors and coping strategies of weight stigma experienced by obese women. 

Objectives

The current study attempted to fulfil the following objectives:

• To explore the psychosocial experiences of young women with obesity along with the extent, impact, and sources of weight-based stigmatization.
• To examine the coping behaviors used by young obese women.

Research Questions

Following research questions were addressed by the current study:

• What are the psychosocial experiences of young obese women?
• What is the extent and impact of weight-based stigmatization on young obese women?
• What is the source of stigma and where were they stigmatized?
• What are the coping behaviors employed by young obese women?

Method

Research Design

The current study employed qualitative research design using the interpretative phenomenological approach to assess the lived experiences of young women with obesity. The phenomena was evaluated by keeping the personal biases aside. Reflective technique was executed because interpretative phenomenological analysis (IPA) provided this freedom to incorporate more representative image of preparation and interpretation of the experience to be lived. The current study attempted to evaluate the in-depth and holistic views of individuals experiencing the situation of living with obesity (Smith & Osborn, 2004).

Participants

Six young obese women were interviewed for the current research. They were categorized as obese on the basis of their BMI value equal to 30 or greater than 30 kg/m². Unmarried young obese women within the age range of 19-25 years who have been obese for the last two years, while married women and those with any medical conditions were excluded. Participants were recruited from ladies gyms of Lahore city using non-probability purposive sampling strategy and these criteria align with IPA (Smith & Obsorn, 2007).

Table 1

Summary of Key Participant’s Characteristics

Procedure

Firstly, the study was approved from the institutional review board. Following that an interview protocol was designed to collect information about the desired topic related to the participants. It was made explicit that the interviews would be audio recorded in both the participant information sheet and the informed consent form. Participants were assured that their involvement in the study was entirely voluntary and that they may withdraw at any moment due to any reason. Acronyms for patients' pseudonyms were utilized to guarantee that participants were never recognized. Interviews were conducted in Urdu and prompts were employed to elaborate the questions. The participants were encouraged to provide detailed information in their own way. The duration of interviews ranged from 30-45 minutes and each participant narrated their experiences in a single session which were recorded and transcribed. Following the interviews, participants were debriefed and were encouraged to ask further questions. At the conclusion of interviews, a quick therapeutic counselling session was also offered to the participants by the researcher. Anonymity and confidentiality were guaranteed. The original language (Urdu) transcriptions were translated into English. The transcribed data was anonymized to maintain the confidentiality of the participants.  During the interviews, the interviewer requested the interviewees to explain any points that were unclear or ambiguous.

Interview Guide

To gather information about the lived experiences and coping mechanisms of young obese women, a semi-structured interview guide was developed. By integrating an adaptable framework with an appropriate direction from the interviewer, this technique frequently generates comprehensive and perceptive information from applicants. As the interviewer and interviewee assist one another on a common path of comprehension and sense-making, semi-structured interviews resemble an empowering tool (Galletta & Cross, 2013). Interview protocol was designed to cover the major domains of topic of interest, especially the difficulties, obstacles, desires, and coping behaviors. Interview protocol was structured by using three main questions, twenty-four probing questions covering the experiences, obstacles, difficulties, coping behaviors, and behaviors of society to explore the lived experiences of participants.

Data Analysis

The current study was based on a small sample as recommended by IPA. Each transcript was examined in detail. IPA was used to analyze the transcripts. The researcher can identify themes and integrate them into clusters through logical steps that facilitate the interpretive process. The following analysis was done on the data (Smith, 2016).

Step I: Reading and Rereading

The researcher read and reread the verbatim and transcripts multiple times, envisioning the participant's voice as we read. The audio was listened to after reading the transcript. - This reading and rereading aided in understanding how rapport and trust were formed during an interview and also helped to identify more profound and more particular areas.

Step 2: Make a Note

Once the researcher receives an overview of the data, basic note-taking begins. The transcript had a large margin on the left and was numbered. The aim was to help find themes. During note taking, semantic content and language usage were kept in view. Transcript was reviewed for any exciting or striking points. This process helped familiarize the transcript and uncover distinct ways in which respondents speak and comprehend. Moreover, during this phase, a descriptive core of remarks focused on phenomenology and was kept close to the participant's explicit meaning which was underlined—interpretative notes aided in understanding the participants' problems. The participants' non-verbal language, their thoughts about the context of their worries, and identification of abstract ideas all helped to make sense of the meaning patterns observed.

Step 3: Emergent Themes

The process of abstraction began after the notes were appended to the transcript's left margin. The bulk of transcript and initial notes was reduced, however, the intricacy of mapping interrelationships, linkages, and patterns among exploratory notes was kept. This required a change in analytic focus from the transcript to the original notes. Themes were placed in a margin to the right of the data section they accompanied.

Step 4: Connecting Emerging Themes

Afterwards, links were found out between themes to define meaningfully and identify "superordinate" themes. It was now possible to identify the “superordinate” theme by comparing the sub-themes. Smith and Osborn (2004) advised researchers to “imagine a magnet, with some themes drawing others in and helping to make sense of them”.

Step 5: Next Case

Every case was searched to identify new and unexpected themes and the process was repeated. Each transcript was considered separately with the first case's ideas being bracketed while working on the second.

Step 6: Finding Themes in Cases

This step considered cross-case connections and how a theme in one case helped highlight another by taking into account the convergent and divergent transcripts. A new set of themes was created including subordinate/subthemes, themes, and superordinate themes.

Table 2

Master Table of Themes

Results

Thirty-five (35) subthemes were discovered as a consequence of the investigation. Five superordinate themes included loss (self/social), psychological consequences (negative thoughts/emotions), concerns (physical/future), interpersonal challenges, and coping strategies.

Loss (Self/Social)

All women reported experiencing social loss, self-loss or both including loss of self-confidence, loss of self-esteem, and loss of positive self-image. They became less confident after gaining weight which indicated that they are influenced by beauty standards set by the society. They reported:

I have a lot of confidence problems. I was so confident before this happened to me...like I used to click a lot of photos, good photos came from every angle, but now I am not very confident about myself. I have to take care of my dressing. I used to wear jeans and tights, but now I am very selective about my dressing. (Participant-C)

“I feel bad about myself. I considered myself a beautiful girl, but now I don't think so”. (Participant-A)

“I feel bad about myself. When you are going somewhere, everyone looks at you, and then people make fun of you. And you can't even say anything to them.” (Participant-B)

“I was very confident, but now I don't talk in front of people. I think I will be prominent, and people will judge me”. (Participant-A)

“I do not feel confident in crowded places”. (Participant-E)

“My self-image or self-esteem has been affected a lot. I do not participate in sports days or extracurricular activities. I think that I will not be able to do it”. (Participant-C)

“I don't feel good about myself like I think I have to lose weight.” (Participant-D)

They lost their old friends, and they faced avoidance and ignorance by friends. They were mocked by family members, friends, and relatives. One of them reported:

“I faced discrimination by friends. Beauty-conscious friends started avoiding me when I gained weight.”  (Participant-B)

“Relatives, family, and friends all make fun of my body weight.” (Participant-A)

“Friends ignore me like they are not okay with me.” (Participant-D)

“My brother started mocking me when I gained weight. They used to call me Moti instead of my name.” (Participant-E)

“Those who were beauty-conscious became distant”. (Participant-C)

“People avoid you just on the basis of your body weight.” (Participant-C)

“Friends make fun of me.” (Participant-B)

They got rejected due to their body weight. This is because slim body is considered as one of the criteria to get married in our society. They reported:

“I had a marriage proposal, but they refused. The reason was my obesity.” (Participant-B)

“I had two marriage proposals, one of them indirectly showed that they are rejecting because of my weight, but one of them said directly to my mother that your daughter looks older than age”. (Participant-C)

Psychological Consequences

Women reported psychological consequences in the form of negative emotions and thoughts, such as being anxious and stressed when they look at their body weight or when they have to go out. They also considered themselves worthless on the basis of their weight. One of them reported:

“I feel sad and anxious when I look at myself.” (Participant-E)

“I feel anxious whenever I have to go out.” (Participant-A)

“I feel like I am worthless.” (Participant-D)

Concerns

Women were concerned about looking older and uglier. They thought that their body weight makes them less physically attractive and they are not fulfilling the beauty standards. The only future concern they reported was the fear of not being able to get married or get suitable proposal for them. According to one of them:

“I have anxiety that I have to face proposal rejection because of my body weight.” (Participant-D)

“I feel anxious thinking that the time of my marriage is near, so I don't have to face rejection because of this body weight.” (Participant-A)

Interpersonal Challenges

Interpersonal challenges faced by obese women included how their family, friends, and strangers perceived them and talked about their body weight. They reported that their family members advise them all the time, friends make offensive comments, and strangers gave judgmental looks.

“Mama always says to control your body weight; otherwise, it leads to medical problems”. (Participant-E)

“Family members are all the time talking about the benefits of being slim.”  (Participant-A)

“Friends make offensive comments and give backhanded compliments as they taunt me like you are getting prettier day by day, but their point behind is that you are gaining weight day by day” (Participant-B)

“Strangers give judgmental looks”. (Participant-B)

“Strangers stare and give unwanted attention”. (Participant-C)

Coping Strategies

Women use both adaptive and maladaptive coping strategies to cope with their body weight along with psychological distress they have to face because of their body weight. Some adaptive strategies they adopted are:

“I exercise and walk to maintain my body weight and maintain my diet.” (Participant-D)

“I try to console myself by positive self-talking. Don't worry; I will be in better shape when you control your diet.” (Participant-A)

“I try to seek help from non-judgmental friends.” (Participant-E)

Most of the women adopt maladaptive strategies to cope with their psychological distress. They reported:

“I have started avoiding social gatherings”.  (Participant-C)

“When I get stressed because of my body weight, I tend to eat more.” (Participant-E)

“I don't participate in class in front of friends, fellows, and teachers and I become reluctant to seek help from others.” (Participant-A)

“I try not to eat in front of others.” (Participant-B)

“I try not to participate in class so that I will not become the center of attention. I think being invisible is the best coping strategy.” (Participant-A)

“I try to be friends with fat people so that I will not get prominent.” (Participant-B)

Discussion

The current study shed light on lived experiences of young women with obesity regarding their psychological and social experiences along with coping behaviors they adopted. The five superordinate themes that emerged were concerning loss of self and social loss, physical and future concerns, psychological consequences such as negative emotions and thoughts, interpersonal challenges, and adaptive and maladaptive coping strategies they adopted to cope with their obesity and associated distress. Young obese women face many psychosocial concerns and challenges. They lose their self-confidence and self-esteem after gaining weight. They face loss of their positive self-image due to their body weight.

Previous research indicates that people with obesity face many problems pertaining to their self-confidence and self-esteem (Lewis et al., 2011; Memon et al., 2019). Their family, friends, and even relatives mock them on the basis of their looks. They face social rejection. People with obesity are not socially accepted (Langford et al., 2022). Young adulthood is the prime-time period when people go for marriages, and in our society, many young women get rejected due to their weight (Mosman et al, 2015).

The current study also indicates that four out of six women got rejected just because their weight is not according to the beauty standards of our society. Women’s future concerns are only confined to their fear of not being able to get married due to their body weight. They feel anxious to go out in social gatherings because everyone gives them judgmental looks and unwanted attention. Interpersonal challenges they faced include unsolicited advices from their family members, offensive comments by friends, unwanted attention, and judgmental looks by strangers. People judge others just on the basis of their body weight and they blame everything terrible that happens to them on their weight (Gerend et al., 2022; Rafeh & Hanif, 2020).

Women use more maladaptive coping behaviors than adaptive coping behaviors to cope with psychological distress. It seems like adopting maladaptive coping strategies is convenient for them since adaptive coping strategies demand a lot of effort. Maladaptive coping strategies they used included emotional eating when they felt stressed. They tend to avoid social gatherings because they do not want to hear the offensive comments of others. They avoid participating in co-curricular activities, moreover they also try not to present in their classes to avoid getting prominent. They are usually reluctant to seek help from their teachers or other people just because other people do not notice them or tease them due to their weight. They try to befriend people facing obesity issues so that they would not get prominent. People are more inclined towards using maladaptive coping strategies than adaptive coping strategies (Langford et al., 2022). According to the study, they were not consistent in adopting adaptive strategies, however, they tried to exercise, walk, and maintain their diet to lose weight. People with obesity felt an individual responsibility to lose their weight by maintaining their diet and by doing exercise (Laar et al., 2020; Thomas et al., 2008). Evidence indicates that weight-based stigmatization is similar in both the West and the East. The experiences reported by females are consistent with the findings from Western cultures.

Conclusion

The ideas of hermeneutics, phenomenology, and ideography are at the heart of the Interpretative Phenomenological Approach (IPA). The current study aimed to get a better understanding of the experiences and issues faced by young obese women in Pakistan. Moreover, it also examined what coping strategies they employed to cope with weight-based stigmatization. Findings revealed that obese women experienced low self-esteem and had poor self-image due to weight stigmatization and they considered themselves as less attractive. They experienced interpersonal challenges and psychological consequences due to their obesity.

Limitations and Suggestions

The data for the current study was collected exclusively from Lahore. Future research should include individuals from other cities as well to enhance the generalizability of results. Longitudinal studies can also be conducted as they are helpful while determining as to how young women with obesity deal with their feelings and experiences over time. By following these women for a long period, researchers can see how their self-esteem and mental health evolve and what coping strategies work best for them in different situations.

Implications

The current study will help introduce effective methods and plans to enhance the use of adaptive coping mechanisms by obese and other individuals who are victims of stigma. Furthermore, it encourages establishment of community-based weight loss awareness/treatment programs by offering analysis into the underlying components of weight stigma like family and friends should help them to cope with this rather than just criticizing them and coping techniques like focusing on adaptive coping strategies like maintaining diet or regular physical activities. This study has implications for therapists and healthcare professionals developing effective interventions for obese women. It also provides guidelines for women facing obesity issues to deal with stress and to adapt healthy coping strategies rather than maladaptive coping strategies. Moreover, this study may also be helpful to develop awareness programs aimed at individuals, enabling them to provide social and emotional support to obese people. Promoting social connections and supporting networks might be helpful for obese people to cope with stress and anxiety linked to their weight.

References

Aparicio-Martinez, P., Perea-Moreno, A. J., Martinez-Jimenez, M. P., Redel-Macías, M. D., Pagliari, C., & Vaquero-Abellan, M. (2019). Social media, thin-ideal, body dissatisfaction and disordered eating attitudes: An exploratory analysis. International Journal of Environmental Research and Public Health, 16(21), 4177–4193. https://doi.org/10.3390/ijerph16214177  

Bays, H. E., Ng, J., Sicat, J., & Look, M. (2022). Obesity pillars roundtable: Obesity and East Asians. Obesity Pillars, 2, Article e100011. https://doi.org/10.1016/j.obpill.2022.100011

Blodorn, A., Major, B., Hunger, J., & Miller, C. (2016). Unpacking the psychological weight of weight stigma: A rejection-expectation pathway. Journal of Experimental Social Psychology, 63, 69–76. https://doi.org/10.1016/j.jesp.2015.12.003  

Branigan, A. R. (2017). (HOW) Does obesity harm academic performance? Stratification at the intersection of race, sex, and body size in elementary and high school. Sociology of Education, 90(1), 25–46. https://doi.org/10.1177/0038040716680271  

Cuzzolaro, M., & Fassino, S. (2018). Body image, eating, and weight: A guide to assessment, treatment, and prevention. Springer International Publishing.

Farrell, E., Hollmann, E., le Roux, C. W., Bustillo, M., Nadglowski, J., & McGillicuddy, D. (2021). The lived experience of patients with obesity: A systematic review and qualitative synthesis. Obesity reviews: An Official Journal of the International Association for the Study of Obesity, 22(12), Article e13334. https://doi.org/10.1111/obr.13334

Fruh, S. M., Graves, R. J., Hauff, C., Williams, S. G., & Hall, H. R. (2021). Weight bias and stigma: Impact on health. The Nursing Clinics of North America, 56(4), 479–493. https://doi.org/10.1016/j.cnur.2021.07.001  

Galletta, A. & Cross, W. E. (2013). Mastering the semi-structured interview and beyond: From research design to analysis and publication. NYU Press. https://doi.org/10.18574/nyu/9780814732939.001.0001

Gerend, M. A., Patel, S., Ott, N., Wetzel, K., Sutin, A. R., Terracciano, A., & Maner, J. K. (2022). A qualitative analysis of people's experiences with weight-based discrimination. Psychology & Health, 37(9), 1093–1110. https://doi.org/10.1080/08870446.2021.1921179

Giel, K. E., Thiel, A., Teufel, M., Mayer, J., & Zipfel, S. (2010). Weight bias in work settings – A qualitative review. Obesity Facts, 3(1), 33–40. https://doi.org/10.1159/000276992  

Hays, N. P., & Roberts, S. B. (2008). Aspects of eating behaviors “disinhibition” and “restraint” are related to weight gain and BMI in women. Obesity (Silver Spring), 16(1), 52–58. https://doi.org/10.1038/oby.2007.12  

Hayward, L. E., Vartanian, L. R., & Pinkus, R. T. (2018). Weight stigma predicts poorer psychological well‐being through internalized weight bias and maladaptive coping responses. Obesity (Silver Spring), 26(4), 755–761. https://doi.org/10.1002/oby.22126  

Janjua, M. M., Khan, A., & Kamal, A. (2022). Effect of exposure to media images on self-esteem, body esteem, and body image anxiety of college students in Pakistan. International Journal of Psychotherapy, Counselling, & Psychiatry, 28, 362-397. http://dx.doi.org/10.32598/ijpcp.28.3.4060.4

Khan, A. N., Khalid, S., Khan, H. I., & Jabeen, M. (2021). Impact of today’s media on university student’s body image in Pakistan: A Conservative, developing country’s perspective. BMC Public Health, 11(1), Article e379. https://doi.org/10.1186/1471-2458-11-379  

Kite, J., Huang, B.-H., Laird, Y., Grunseit, A., McGill, B., Williams, K., Bellew, B., & Thomas, M. (2022). Influence and effects of weight stigmatisation in media: A systematic review. eClinicalMedicine, 48, Article e101464. https://doi.org/10.1016/j.eclinm.2022.101464  

Laar, R. A., Shi, S., Ashraf, M. A., Khan, M. N., Bibi, J., & Liu, Y. (2020). Impact of physical activity on challenging obesity in Pakistan: A knowledge, attitude, and practice (KAP) study. International Journal of Environmental Research and Public Health, 17(21), 7802. https://doi.org/10.3390/ijerph17217802  

Langford, R., Davies, A., Howe, L., & Cabral, C. (2022). Links between obesity, weight stigma and learning in adolescence: A qualitative study. BMC Public Health, 22(1), 109–118. https://doi.org/10.1186/s12889-022-12538-w  

Lewis, S., Thomas, S. L., Blood, R. W., Castle, D. J., Hyde, J., & Komesaroff, P. A. (2011). How do obese individuals perceive and respond to the different types of obesity stigma that they encounter in their daily lives? A qualitative study. Social Science & Medicine, 73(9), 1349–1356. https://doi.org/10.1016/j.socscimed.2011.08.021  

Memon, R. S., Shaikh, M. Y., Shaikh, A., & Ochani, R. K. (2019). Psychosocial predictors of weight bias among undergraduate students of Karachi, Pakistan. Journal of Global Health Reports, 3, Article e2019087. https://doi.org/10.29392/joghr.3.e2019087  

Mosman, S. C., Poggenpoel, M., & Myburgh, C. (2015). Life stories of young women who experience rejection from their mothers. Curationis, 38(1), Article e1429. https://doi.org/10.4102/curationis.v38i1.1429  

Munir, M., & Dawood, S. (2021). Weight stigma and disordered eating behaviors in Pakistani overweight adolescents: The mediating role of body esteem. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, 26(6), 1939–1948. https://doi.org/10.1007/s40519-020-01038-8  

Poynter, A. S. (2020). The lived experience of obesity, spirituality, and health behaviors in African American women [Doctoral dissertation, East Tennessee State University]. https://dc.etsu.edu/cgi/viewcontent .cgi?article=5330&context=etd

Rafeh, A., & Hanif, R. (2020). Understanding perception of weight stigma: Development and validation of Perceived Weight Stigmatization Scale. Pakistan Journal of Psychological Research, 34(4), 869–897. https://doi.org/10.33824/pjpr.2019.34.4.47  

Randall-Arell, J., & Utley, R. (2014). The adolescent female’s lived-experience of obesity. The Qualitative Report, 19(23), 1–15. https://doi.org/10.46743/2160-3715/2014.1219  

Schwartz, M. W., Seeley, R. J., Zeltser, L. M., Drewnowski, A., Ravussin, E., Redman, L. M., & Leibel, R. L. (2017). Obesity pathogenesis: An endocrine society scientific statement. Endocrine Reviews, 38(4), 267–296. https://doi.org/10.1210/er.2017-00111  

Smith, J. A. (2016). Interpretative phenomenological analysis: Getting at lived experience. The Journal of Positive Psychology, 12(3), 303–304. https://doi.org/10.1080/17439760.2016.1262622  

Smith, J. A., & Osborn, M. (2004). Interpretative phenomenological analysis. In G. M. Breakwell (Ed.) Doing social psychology research (pp. 229–254). The British Psychological Society and Blackwell Publishing Ltd. https://doi.org/10.1002/9780470776278.ch10  

Smith, J. A., & Osborn, M. (2007). Pain as an assault on the self: An interpretative phenomenological analysis of the psychological impact of chronic benign low back pain. Psychology & Health, 22(5), 517–534. https://doi.org/10.1080/14768320600941756  

Stroebe, W. (2022). The goal conflict model: A theory of the hedonic regulation of eating behavior. Current Opinion in Behavioral Sciences, 48, Article e101203. https://doi.org/10.1016/j.cobeha.2022.101203  

Tanveer, M., Hohmann, A., Roy, N., Zeba, A., Tanveer, U., & Siener, M. (2022). The current prevalence of underweight, overweight, and obesity associated with demographic factors among Pakistan School-aged children and adolescents—an empirical cross-sectional study. International Journal of Environmental Research and Public Health, 19(18), Article e11619. https://doi.org/10.3390/ijerph191811619  

Thomas, S. L., Hyde, J., Karunaratne, A., Herbert, D., & Komesaroff, P. A. (2008). Being ‘fat’ in today’s world: A qualitative study of the lived experiences of people with obesity in Australia. Health Expectations, 11(4), 321–330. https://doi.org/10.1111/j.1369-7625.2008.00490.x  

Verstuyf, J., Patrick, H., Vansteenkiste, M., & Teixeira, P. J. (2012). Motivational dynamics of eating regulation: A self-determination theory perspective. The International Journal of Behavioral Nutrition and Physical Activity, 9, Article e21. https://doi.org/10.1186/1479-5868-9-21

Wadden, T. A., & Bray, G. A. (Eds.). (2018). Handbook of obesity treatment (2nd ed.). The Guilford Press.

World Health Organization. (2020, February 21). Obesity. https://www.who.int/health-topics/obesity