The Roles of Weight Stigma, Emotion Dysregulation, and Eating Pathology in Suicide Risk

Abstract

Accepted for publication at Body Image. 10.1016/j.bodyim.2021.04.005
Using an interpersonal theory of suicide and affect regulation framework, we investigated the relationships between perceived burdensomeness, thwarted belongingness, weight stigmatization, emotion dysregulation, eating pathology, and suicide risk. Three main hypotheses were investigated. First, we predicted a positive linear relationship between weight stigmatization and risk. Second, an indirect effect of weight stigmatization on risk via perceived burdensomeness and thwarted belongingness was posited. Third, we hypothesized that weight stigmatization would indirectly affect suicide risk via emotion dysregulation and eating pathology. Undergraduates (N = 156) completed online surveys. Linear regressions and indirect effect analyses were performed. Weight stigmatization was directly, positively associated with increased suicide risk. Weight stigmatization indirectly affected suicide risk via perceived burdensomeness but not thwarted belongingness. Higher stigmatization was associated with higher levels of perceived burdensomeness, which was associated with higher risk. An indirect effect of weight stigmatization on suicide risk through emotional dysregulation emerged. Higher weight stigmatization was associated with higher emotional dysregulation, which was associated with higher suicide risk. When all models were combined, only an indirect effect via perceived burdensomeness remained. Our findings may have clinical and public health implications for suicide prevention among people with weight stigma-related risk factors.
Preregistration: https://osf.io/g9kvy/

Full text

Running head: WEIGHT STIGMA & SUICIDE RISK 1
Accepted for publication at Body Image: An International Journal of Research
The Roles of Weight Stigma, Emotion Dysregulation, and Eating Pathology in Suicide Risk
Valerie J. Douglas, Ph.D.1*, Mun Yee Kwan, Ph.D.2, and Kathryn Gordon, Ph.D.1
Author Note:
1North Dakota State University
2West Texas A&M University
*Valerie Douglas is now at San Diego State University.
Correspondence concerning this paper should be directed to Valerie Douglas, 6363
Alvarado Court, Suite 101, San Diego, CA 92120. vjdouglas@sdsu.edu
Abstract

WEIGHT STIGMA & SUICIDE RISK 2
Using an interpersonal theory of suicide and affect regulation framework, we investigated the
relationships between perceived burdensomeness, thwarted belongingness, weight
stigmatization, emotion dysregulation, eating pathology, and suicide risk. Three main hypotheses
were investigated. First, we predicted a positive linear relationship between weight
stigmatization and risk. Second, an indirect effect of weight stigmatization on risk via perceived
burdensomeness and thwarted belongingness was posited. Third, we hypothesized that weight
stigmatization would indirectly affect suicide risk via emotion dysregulation and eating
pathology. Undergraduates (N = 156) completed online surveys. Linear regressions and indirect
effect analyses were performed. Weight stigmatization was directly, positively associated with
increased suicide risk. Weight stigmatization indirectly affected suicide risk via perceived
burdensomeness but not thwarted belongingness. Higher stigmatization was associated with
higher levels of perceived burdensomeness, which was associated with higher risk. An indirect
effect of weight stigmatization on suicide risk through emotional dysregulation emerged. Higher
weight stigmatization was associated with higher emotional dysregulation, which was associated
with higher suicide risk. When all models were combined, only an indirect effect via perceived
burdensomeness remained. Our findings may have clinical and public health implications for
suicide prevention among people with weight stigma-related risk factors.
Keywords: Weight stigmatization, disordered eating, emotion dysregulation, suicidal
ideation, suicide risk
The Roles of Weight Stigma, Emotion Dysregulation, and Eating Pathology in Suicide Risk
Western society tends to idealize thinness (Thompson et al., 1999) or a lean and toned
body (Tylka, 2011), which has led to the devaluation of higher-weight bodies and the use of
societal bias towards those with higher-weight bodies to promote weight loss (Puhl et al., 2012;

WEIGHT STIGMA & SUICIDE RISK 3
Rubino et al., 2020). Weight stigmatization includes the discrimination and negative experiences
a person endures due to negative societal biases against people with higher-weight bodies (Puhl
& Brownell, 2001). The rate of weight-based discrimination rose by 66% between 1995 and
2005, a change that is believed to reflect changes in attitudes rather than increases in body size
(Andreyeva et al., 2008). From 2007 to 2016, implicit attitudes towards those in larger bodies
increased, contrary to implicit bias towards many other groups which decreased in this time
period (Charlesworth & Banaji, 2019).
Weight stigmatization is linked to many different negative outcomes and consequences.
Those who suffer weight stigmatization report lower self-esteem, higher body dissatisfaction
(Vartanian & Novak, 2011), higher rates of mood and anxiety disorders, higher rates of drug
dependence, and higher rates of alcohol dependence (Hatzenbeuhler et al., 2009). Disturbingly,
compared to other types of discrimination, those who suffer weight-based discrimination have a
60% increased mortality risk, even when controlling for possible consequences due to weight
(Sutin et al., 2015). Sutin and colleagues (2015) hypothesized that the rise in mortality risk may
be attributed to many negative behavioral and emotional consequences of weight stigmatization
and that often weight stigmatization comes from loved ones who, in other cases of
discrimination, will instead provide support. Indeed, family and friends have been reported as a
top source of weight-based discrimination (O’Hara et al., 2016; Puhl & Brownell, 2001).
One understudied negative outcome linked with weight stigma is suicidality. The current
paper investigates the links between weight stigma and suicidality and fills in gaps related to the
interpersonal theory of suicide, affect regulation, and eating pathology. With the literature
showing that the stigma against larger bodies leads to frequent, consistent discrimination, even
by loved ones, it may not be surprising that evidence is also mounting for a link between weight
stigmatization and suicidality (e.g., Chen et al., 2012; Hunger et al., 2020; Levy & Pilver, 2012).

WEIGHT STIGMA & SUICIDE RISK 4
So far, the literature has found this link to exist for multiple subgroups. In a study of adolescents,
girls who had been teased for their weight by both a family member and peers had higher rates of
suicidal ideation and suicide attempts than those who had not experienced any teasing (Eisenberg
et al., 2003). More than half of the participants who were teased for their weight both at school
and by a family member had suicidal ideation compared to a quarter of participants who were not
teased. Additionally, 25% of participants who had been teased had attempted suicide as
compared to 8.5% who had not been teased (Eisenberg et al., 2003).
In a sample of bariatric surgery-seeking adults, weight stigma was related to increased
suicidality in women but had no relationship to suicidality in men (Chen, et al., 2012). In a large,
nationally representative US sample, individuals who were formerly classified with an
overweight body mass index (BMI) but who had lost weight were significantly more likely to
have attempted suicide compared with individuals who were currently in the overweight BMI
range and those who never met the overweight BMI criteria (Levy & Pilver, 2012). Perceived
weight discrimination partially mediated this relationship. This finding suggests that weight
discrimination experiences, especially since childhood, may have long-lasting psychological
effects even after an individual moves out of the stigmatized group (Levy & Pilver, 2012). A
more recent study also found a link between weight-based discrimination and suicidal ideation in
community samples (Hunger, et al., 2020). Hunger and colleagues’ (2020) study laid the
groundwork for investigating the link between weight stigma and suicidality within theoretical
contexts, such as the interpersonal theory of suicide.
The interpersonal theory of suicide
The interpersonal theory provides a useful framework for understanding suicidality (IPT;
Chu et al., 2017; Joiner, 2005; Van Orden et al., 2010). The IPT purports that three key constructs
combine to increase suicide risk: Thwarted belongingness, perceived burdensomeness, and

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capability (Joiner, 2005; Van Orden et al., 2010). The IPT suggests that humans have a
psychological need to feel connected to others and when this need is unmet, people experience
thwarted belongingness (TB). Specifically, TB is a sense of loneliness, negative feelings about a
lack of social connections, and a perception of a lack of reciprocal, caring relationships.
Perceived burdensomeness (PB) is the perception that a person is a burden on others and the
world would be better off without them in it. PB is characterized by elevated amounts of self-
hatred and the individual’s belief that their flaws outweigh their worthiness. The theory states
that individuals with both TB and PB may desire suicide. This is especially true if the individual
feels a sense of hopelessness about their belongingness or burdensomeness state ever changing.
If the individual assesses these states as being transient, then the suicidal desire may be lower or
absent. While TB and PB, along with a sense of hopelessness, can combine to predict suicidal
desire, this combination does not mean that an individual will necessarily act on it through a
lethal or near-lethal suicide attempt (Joiner, 2005; Van Orden et al., 2010). For tragic outcomes,
an individual must also be capable of suicide by overcoming natural instincts of self-preservation
and aversion to fearful and painful stimuli (Chu et al., 2017; Joiner, 2005; Van Orden et al.,
2010).
This interpersonal theory of suicide framework may be useful for advancing the scientific
understanding of weight stigma as a risk factor for suicide. For example, experiences of
discrimination could lead to people feeling like outsiders in society and increase TB. This may
especially be true when family and friends, whom we are meant to “belong” with, are some of
the top perpetrators of weight stigma (O’Hara, et al., 2016; Puhl & Brownell, 2001).
Additionally, devaluation of individuals in larger bodies may foster perceptions that one is
worthless or a burden in a society that praises thinness and stigmatizes those who do not attain it.

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Hunger and colleagues’ (2020) research supports these hypotheses; they reported that weight-
based discrimination was associated with increased suicidal ideation and PB. The current study
expands on their work by exploring weight stigma and the IPT within the context of emotion
dysregulation.
Emotion dysregulation and the interpersonal theory
Emotion dysregulation is a transdiagnostic risk factor linked to psychopathology in
general (Fowler et al., 2014) and suicide in particular (Linehan, 1993). Emotion dysregulation
can be conceptualized as a general inability to utilize adaptive coping with one’s emotions (Gratz
& Roemer, 2004). In particular, Gratz and Roemer’s (2004) clinically relevant conceptualization
of emotion dysregulation proposes six distinct dimensions: nonacceptance of emotional
responses, difficulties engaging in goal-directed behavior, impulse control difficulties, lack of
emotional awareness, limited access to emotion regulation strategies, and lack of emotional
clarity. This model of affect regulation has been useful in differentiating those who have multiple
suicide attempts and those who have never attempted with no suicidal ideation (Rajappa et al.,
2012) and some support linking emotion dysregulation to suicidal desire and lifetime suicide
attempts has been found (Anestis & Joiner, 2011).
In terms of the IPT, emotion dysregulation has been linked to different components of the
IPT such as suicidal desire (Anestis & Joiner, 2011) and capability (Bender et al., 2012). It has
been theorized that individuals with increased emotion dysregulation have greater impulse
control difficulties and limited access to more regulated ways of coping, so they may have
increased capability due to the increased likelihood of engaging in painful and provocative
events such as non-suicidal self-injury (Bender et al, 2012). In addition, as individuals with
increased emotion dysregulation may lack the tools to cope with increased negative affect and
become overwhelmed, they may also be more likely to have increased suicidal desire as an

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escape from intense emotions (Anestis et al., 2011). Thus, these individuals may be at risk via
multiple components of the IPT.
The literature has been mixed, however, in the support for this extension of the IPT. One
study found support for emotion dysregulation being a potential protective factor (Anestis et al.,
2010). To elucidate these non-theorized findings, Heffer and Willoughby (2018) conducted a
four-wave longitudinal study of emotion dysregulation and the IPT and found support for two
distinct paths. Overall, it was discovered that emotion dysregulation led to increases in TB and
PB over time. The indirect path found that emotion dysregulation predicted more non-suicidal
self-injury (painful and provocative events) over time and led to higher capability over time,
making it a risk factor. The direct path found that emotion dysregulation predicted lower
capability over time for those who do not self-injure, making it a protective factor. It was
proposed that emotion dysregulation, and in particular low distress tolerance, is related to the
inability to tolerate the painful and fearful experiences associated with suicidality and thus may
protect individuals in the direct path. For those in the indirect path, however, emotion
dysregulation was no longer protective, perhaps due to their habituation to fear and physical pain
from their recurrent non-suicidal self-injury (Heffer & Willoughby, 2018).
For the current study, we examined the links between weight stigma and the IPT with the
addition of emotion dysregulation to build upon the work of Hunger et al. (2020) and due to the
links between stigma and emotion dysregulation. Prior research has found that discrimination
based upon a socially minoritized identity and the stress of dealing with this discrimination may
lead to exacerbation of emotion dysregulation due to the individual experiencing drained
emotional resources (Hatzenbuehler, 2009). This literature has been proposed to be relevant to
the weight stigma field as well (Sikorski et al., 2015), suggesting that those who experience
weight-based discrimination may experience trouble regulating their emotions. In addition,

WEIGHT STIGMA & SUICIDE RISK 8
weight stigma has been linked to emotion dysregulation (Douglas & Varnado-Sullivan, 2016).
Essentially, in addition to those experiencing weight stigma and thus enduring increased PB and
TB, those with increased emotion dysregulation may be at greater risk due to greater difficulty
moderating intense negative affect instigated by episodes of weight stigma. In addition, due to
the chronicity of weight stigma, individuals’ emotion regulation skills may be drained
(Hatzenbuehler, 2009), leading them to have a harder time tolerating these negative affective
states.
In the current study, we examine PB and TB, but we did not directly examine capability
for suicide or frequency of painful and provocative events. However, we investigated one
relevant factor to weight stigma and suicide, eating pathology, as a preliminary step towards
investigating potential paths as suggested by Heffer and Willoughby (2018). Weight
stigmatization has been linked to numerous forms of eating pathology at both clinical and
subclinical levels, including emotional eating (Hübner et al., 2016), overeating (Sutin et al.,
2016), binge eating (Almeida et al., 2011; Friedman et al., 2012), purging via vomiting, and
weight/shape concerns (Goel et al., 2018). Furthermore, eating disorders and eating pathology
are linked to suicidal ideation (e.g., Forrest et al., 2016; Goel et al., 2018), suicide attempts
(Smith, Zuromski et al., 2018), and dying by suicide (Arcelus et al., 2011; Chesney et al., 2014;
Crow et al., 2009).
Studies exploring connections between suicidality and eating pathology through the IPT
have produced inconsistent results. Some have found support for the link, such as one study
which found that many forms of eating pathology were related to PB and TB in relation to
suicide risk (Kwan et al., 2017), and a meta-analysis found that eating pathology and eating
disorders significantly predicted suicide attempts (Smith, Velkoff et al., 2018). However, other

WEIGHT STIGMA & SUICIDE RISK 9
studies have found mixed and inconsistent results (e.g., Dodd et al., 2014; Forrest et al., 2016).
Some have found support for the link to eating pathology and PB, but not TB (Forrest et al.,
2016), and in a clinical eating disorder sample, Smith and colleagues (2016) found that there
were no expected theory-consistent interactions (e.g., the combination of TB and PB was not
associated with suicidal desire), but that PB was directly associated with suicidal desire and that
the combination of PB and fearlessness about death was associated with past suicide attempts.
Consequently, the authors called into question the validity of the IPT for eating disorders (Smith
et al., 2016).
Despite these mixed results, eating pathology is an important variable to examine in
relation to the IPT when considering affect regulation. In the general eating disorder literature,
there has been support for the notion that those with eating disorders (e.g., Brockmeyer et al.,
2014) and eating pathology (e.g., Lavender et al., 2014; Ty & Francis, 2013) display high
amounts of emotion dysregulation. In certain affect regulation theories, such as the emotional
cascade model (Selby et al., 2008), eating pathology behaviors are seen as dysregulated
behaviors utilized to modify intense affect so the link between eating pathology and emotion
dysregulation is theoretically consistent. As weight stigma has relations to both eating pathology
and emotion dysregulation (Douglas & Varnado-Sullivan, 2016), it could be theorized that
individuals who experience weight stigma and have increased emotion dysregulation may utilize
eating pathology behaviors in an attempt to regulate their emotions.
Current study
In the current study, we sought to replicate and extend Hunger and colleagues (2020) by
directly testing hypotheses about the IPT and weight stigma, exploring this within the context of
affect regulation, and adding relevant dysregulated behaviors such as eating pathology. The
current paper is based on a pre-registered study (Douglas et al., 2018) which was created before

WEIGHT STIGMA & SUICIDE RISK 10
data were accessed (Douglas, Gordon et al., 2019). During peer review, the analyses and scope of
the paper were changed, however, the spirit of open science was applied to the changes as well.
Previous versions of the paper based upon the original pre-registration can be found as pre-prints
(Douglas, Kwan et al., 2019). In line with past research findings that weight stigma increases
suicide risk, it was hypothesized that weight stigmatization would be directly and positively
associated with suicide risk (e.g., Chen et al., 2012; Eisenberg et al., 2003; Levy & Pilver, 2012).
Second, in line with IPT predictions, we posited that there would be an indirect effect of weight
stigmatization on suicide risk via both PB and TB (see Figure 1). Third, it was predicted that
there would be positive, indirect effects of weight stigmatization on suicide risk via emotion
dysregulation and eating pathology (see Figure 2a). Hypothesis three was modified from pre-
registration, after peer review.
Method
Participants
The sample was drawn from an Institutional Review Board-approved parent study of a
larger dataset that investigated the role of weight stigma in a laboratory test of binge eating
behavior. Although related, all analyses reported herein are separate and unique from other
investigations of this dataset. Participants were recruited online from the psychology department
pool of undergraduate students in a mid-size Midwestern university and the study was advertised
as a generic study of “behavior and emotions.” Participants completed electronic informed
consent and debriefing. There were 156 participants (25.6% men and 74.4% women) between
the ages of 18-33 years. The ethnic/racial composition of the sample was 2.6% Hispanic, 0.6%
American Indian or Alaskan Native, 4.5% Asian, 0.6% Native Hawaiian or Pacific Islander,
3.2% Black or African American, and 91% White or Caucasian. Participants had a BMI range of
15.06-50.89 (M = 24.81, SD = 5.38)1.
1 We chose to not utilize BMI in our analyses due to a recent meta-analysis by Haynes et al.
(2019) which found that the association between objective weight/BMI and suicidality was better

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Procedures
The participants completed measures of perceived stigma, emotional dysregulation,
eating pathology, TB, PB, and suicide risk. After completion of the study, participants were
debriefed and given mental health resources specific to eating pathology and suicidality.
Participant responses to survey questions about suicide risk were monitored, and participants
were contacted by the study authors for further assessment and clinical referral as needed.
Participants received departmental participation credit.
Measures
Weight-based stigmatization experiences. To assess participants’ experiences with
weight-based stigmatization, 12 items that assess low-level stigmatization likely to be reported
by students were selected from the Meyers and Rosen’s (1999) Stigmatizing Situations Inventory
(SSI). We used Puhl and Brownell’s (2006) adaptation of the scoring system in which
participants indicated how often they experienced a stigmatizing situation from “0 (never)” to “3
(once a year or more).” An example item is “Parents or other relatives telling you how attractive
you would be, if you lost weight.” Scores are totaled, with a higher score indicating more
weight-based stigma experiences. The full modified SSI has high internal consistency with a
Cronbach’s alpha of 0.96 (Puhl & Brownell, 2006) and our selection of 12 items had a
Cronbach’s alpha of 0.89 in the current sample.
Emotion dysregulation. Emotion dysregulation was assessed utilizing the Difficulties in
Emotion Regulation Scale (DERS; Gratz & Roemer, 2004). This is a 36-item measure where
participants indicated the amount of time that they displayed the behaviors described in the
items, ranging from “1 (Almost never [0-10%])” to “5 (Almost always [91-100%])”. The DERS
explained by “perceived overweight”. We did include a measure of perceived weight in the
original dataset, however, a one-tailed partial correlation analysis controlling for weight
description found that weight stigma was still significantly correlated to all variables in the study.
Due to the significant results of the partial correlation and the small cell sizes for many of the
weight description options, we chose to not enter perceived weight into the model as it may
introduce under-powered results.

WEIGHT STIGMA & SUICIDE RISK 12
has six subscales: limited access to emotion regulation strategies (ex., “When I’m upset, I believe
that wallowing in it is all I can do”; α = 0.90), lack of emotional awareness (ex., “When I’m
upset, I acknowledge my emotions”; α = 0.82), lack of emotional clarity (ex., “I have no idea
how I am feeling”; α = 0.81), difficulties in engaging in goal-directed behavior (ex., “When I’m
upset, I have difficulty concentrating”; α = 0.82), impulse control difficulties (ex., “When I’m
upset I lose control over my behavior”; α = 0.80), and non-acceptance of emotional responses
(ex., “When I’m upset, I feel guilty for feeling that way”; α = 0.87). Scores are totaled, with
higher scores meaning higher levels of emotion dysregulation. The DERS overall has high
internal consistency (α = 0.93; Gratz & Roemer, 2004) and a Cronbach’s alpha of 0.94 in the
current sample.
Eating pathology. The Eating Disorder Diagnostic Scale (EDDS; Stice et al., 2000; Stice
et al., 2004) was utilized to assess overall eating pathology. The EDDS uses 22-items based on
the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 1994). An example item is, “Has your shape influenced how you think
about (judge) yourself as a person?”. The symptom composite from the EDDS indicates overall
eating pathology severity and was used for analyses. The original syntax for scoring by Stice and
colleagues (2004) was utilized. The EDDS has adequate internal consistency (α = 0.89; Stice et
al., 2004) and a Cronbach’s alpha of 0.81 in the current sample.
Thwarted belongingness and perceived burdensomeness. The Interpersonal Needs
Questionnaire (INQ; Van Orden et al., 2012) is a 15-item measure used to assess perceived TB
and burdensomeness. Participants indicated recently how true a statement is for them on a
Likert-type scale from “1 (not at all true for me)” to “7 (very true for me)”. Scores are summed
for each subscale, with higher scores indicating higher TB or PB. In the current study, only 14
items were used as item number six (“These days, I think I make things worse for the people in

WEIGHT STIGMA & SUICIDE RISK 13
my life.”) was missing from the online survey. We do not believe that this missing item
significantly affects the reliability or validity of the current analyses as we had a Cronbach’s
alpha of 0.88 for the TB subscale and 0.82 for the PB subscale. In addition, many different forms
of the INQ have been found to be as reliable and valid as the full 15-item version, including two
versions excluding item six in particular, which gives credence to the flexibility and robustness
of the INQ (Hill et al., 2015).
Suicide risk. The Suicide Behaviors Questionnaire-Revised (SBQ-R; Osman et al., 2001)
is a four-item scale that was used to assess suicide risk. The items assess lifetime suicidal
ideation and attempts (“Have you ever thought about or attempted to kill
yourself?”, Likert ranging from “Never” to “I have attempted to kill myself, and really hoped to
die.”), ideation over the past year (“How often have you thought about killing yourself in
the past year?”, Likert ranging from “Never” to “Very Often (5 or more times)”), threat of
suicidal behavior (“Have you ever told someone that you were going to
commit suicide, or that you might do it?”, Likert ranging from “No” to “Yes, more than once,
and really wanted to do it”), and the participants’ perception of the likelihood that they will
attempt suicide (“How likely is that you will attempt suicide someday?”, Likert ranging from
“Never” to “Very Likely”). Each question uses a five- or six-point Likert-type scale. A total score
is created by summing the items and a higher score indicates higher suicide risk. The SBQ-R has
adequate validity and reliability (Osman et al., 2001; Campos and Holden, 2019) and had a
Cronbach’s alpha of 0.84 in the current sample. The SBQ-R has demonstrated excellent
predictive validity for changes in suicidal ideation over time (Campos and Holden, 2019). Using
a cut-off score of seven for non-clinical samples (Osman et al., 2001; Campos and Holden,
2019), 13.5% of the sample were at elevated suicide risk. Campos and Holden (2019) found that
those scoring above a seven are 29 times more likely to attempt suicide than those who score

WEIGHT STIGMA & SUICIDE RISK 14
below a seven and Osman and colleagues (2001) found for undergraduates, the cut-off of seven
had a sensitivity of 0.93 and specificity of 0.95.
Statistical Analyses
Analyses were conducted using SPSS (Version 27). All variables were examined for
accuracy of data entry, missing values, and normality. A missing value analysis revealed 4.48%
of data missing. Little’s test indicated that data were missing completely at random, χ2 (18) =
7.64, p = 0.98 and thus, pairwise deletion was used. Skewness and kurtosis range from 0.67 to
2.92 and -0.50 to 9.16, respectively. Logarithm transformations were conducted to weight
stigmatization and suicide risk to meet the assumption of normality for a linear regression
analysis, which was conducted to investigate the association between weight stigmatization and
suicidal risk (Hypothesis 1). No major differences were found for linear regression analysis using
the transformed and untransformed data and thus, results using the untransformed data were
reported for ease of interpretation. The indirect (Hypothesis 2 and 3) and exploratory models
were tested using the PROCESS macro for SPSS, model 4. We used 10,000 randomly generated
samples to generate 95% percentile confidence intervals for the path estimates and indirect
effects (Hayes, 2017).
Results
Original analyses
Descriptive and bivariate correlations are shown in Table 1. Hypothesis 1 was that higher
levels of self-reported weight stigma would be associated with increased suicide risk. Consistent
with that hypothesis, a regression analysis revealed that weight stigmatization was positively
associated with suicide risk, F (1, 150) = 10.55, β = 0.26, p = 0.001. Hypothesis 2 was that there
would be an indirect effect of weight stigmatization on suicide risk via PB and TB. Weight
stigmatization indirectly affected suicide risk via PB (point estimate = 0.13, 95% CI = 0.04,
0.23), but not TB (point estimate = -0.02, 95% CI = -0.06, 0.02). Higher weight stigmatization

WEIGHT STIGMA & SUICIDE RISK 15
was associated with higher PB, which was in turn associated with higher suicide risk (See Table
2).
Exploratory and modified analyses
Analyses not originally pre-registered (Douglas et al., 2018) are included in this section.
In modified hypothesis 3, we predicted that there would be indirect effects of weight
stigmatization on suicide risk via emotion dysregulation and eating pathology. Weight stigma did
directly affect both eating pathology (point estimate = 1.44, 95% CI = 1.11, 1.77) and emotion
dysregulation (point estimate = 1.90, 95% CI = 1.23, 2.56). However, weight stigma only
exhibited an indirect effect via emotion dysregulation (point estimate= 0.06, 95% CI = 0.03,
0.06; See Table 3). To investigate any nuances of facets of emotion dysregulation in the model, a
follow-up indirect effects analysis was conducted with the DERS subscales in place of the total
score for modified hypothesis 3, and eating pathology was not included due to the nonsignificant
finding above (See Figure 2b; See Table 4). Weight stigma directly affected all DERS subscales.
Weight stigma only indirectly effected suicide risk via limited access to emotion regulation
strategies (point estimate = 0.11, 95% CI = 0.003, 0.21). We then conducted a follow-up analysis
entering TB, PB, emotion dysregulation, and eating pathology into the same model 4. We found
differences in the stand-alone analyses versus this analysis (See Figure 3; See Table 5). Weight
stigma directly affected all variables, but only TB and PB directly affected suicide risk. No
indirect effects of weight stigma on suicide risk were found via emotion dysregulation, eating
pathology, or TB. Weight stigma only exerted an indirect effect via PB (point estimate = 0.12,
95% CI = 0.03, 0.23).
Discussion
Previous research has identified a link between weight stigmatization and suicidality
(e.g., Chen et al., 2012); the current study sought to replicate and expand on previous work by
Hunger and colleagues (2020) by examining weight stigmatization and eating pathology within

WEIGHT STIGMA & SUICIDE RISK 16
the context of the IPT and emotion dysregulation. Our findings were consistent with previous
work (Chen et al., 2012; Hunger et al., 2020), as we found that weight stigmatization directly and
positively predicted suicide risk. To elaborate on the basic links between weight stigmatization
and suicide risk within the framework of the IPT and to directly replicate results from Hunger et
al. (2020), an indirect effect analysis was conducted to determine how PB and TB affect the
relationship. We theorized that experiencing discrimination would be linked to TB and
devaluation of larger bodies could foster PB. The hypothesis was partially supported: weight
stigmatization was indirectly related to suicide risk through PB, but not TB. Although the results
were not fully in line with the hypothesis, this pattern is similar to existing literature which
suggests that TB may have a less robust association with suicide risk when statistically
controlling for PB (e.g., Cero et al., 2015; Ma et al., 2016). The results, however, replicated the
results by Hunger and colleagues (2020) who reported that weight-based discrimination was only
related to suicidal ideation via PB. To further investigate weight stigma within the context of the
IPT and integrate affect regulation, we predicted that there would be indirect effects of weight
stigmatization on suicide risk via emotion dysregulation and eating pathology. Weight stigma
was linked to both eating pathology and emotion dysregulation, but only exerted an indirect
effect on suicide risk via emotion dysregulation. We also conducted a follow-up analysis entering
in TB, PB, emotion dysregulation, and eating pathology. Again, weight stigma was directly
linked to these variables, however, weight stigma only exerted an indirect effect on suicide risk
via PB. These sets of analyses have many implications.
First, it is important to highlight that experiencing weight stigma was positively
associated with both TB and PB in all analyses, but PB had the most robust association. This
may be due to the overall trend in the literature that PB is a more robust predictor of suicide risk
within the IPT. However, it also gives credence to the idea that societal views of higher-weight

WEIGHT STIGMA & SUICIDE RISK 17
individuals could contribute to people feeling like a burden. As mentioned previously, society
tends to idealize thinness (Thompson et al., 1999; Tylka, 2011) and stigmatize body weights and
shapes that do not conform to this ideal. It is possible that being stigmatized for one’s weight
contributes to beliefs that one is not as valuable to society as slimmer individuals and leads to
internalized stigma and feelings that one is not worthy (e.g., Hunger et al., 2015). Self-
devaluation and self-hatred could lead to apperceptions that one is a burden on loved ones or
society in general, which may increase suicide risk via the pathway posited by the IPT. This
effect may be compounded by stigmatizing public health campaigns where higher-weight bodies
are sometimes cast as being burdens on society (e.g., Puhl et al., 2012; Rubino et al., 2020). In
addition, the stigma from family and friends (e.g., O’Hara et al., 2016; Puhl & Brownell, 2001),
whom one would assume would be supportive after discrimination but may not be due to the
social acceptability of weight bias (Sutin, et al., 2015), could reinforce these messages and
effects. These points need to be investigated in future longitudinal or qualitative studies.
Second, that weight stigma exerted an indirect effect via emotion dysregulation in one
analysis, but not the other, suggests that emotion dysregulation may be an important variable to
consider in conjunction with weight stigma. However, it may take a backseat when the central
variables in the IPT (TB and PB) are investigated. These analyses suggest that, at least in
conjunction with weight stigma, emotion dysregulation may not be a protective factor and, at
worst, could be a general risk factor outside of the IPT. The same can be said of eating pathology
as well, which weight stigma had no significant indirect effects through in any analysis but was
directly associated with. One interpretation of these analyses is that weight stigmatization may
serve a similar function as non-suicidal self-injury, acting as a painful and provocative event. If
this is the case, it would highlight the extreme pain from being stigmatized for body shape and
weight, putting it in a similar role as other variables, such as trauma, for potentially increasing

WEIGHT STIGMA & SUICIDE RISK 18
capability for suicide. This would be consistent with findings that other types of discrimination
such as racism, can act as painful and provocative events (Brooks et al., 2020). Future research
needs to investigate if weight stigmatization experiences relate to increased capability.
To probe emotion dysregulation further outside of the IPT framework, we conducted a
follow-up indirect effects analysis with the subscales of the DERS in the place of a global
emotion dysregulation scores. We found that weight stigma was directly related to all subscale,
but that weight stigma only exerted an indirect effect on suicide risk via limited access to
emotion regulation strategies (strategies). Gratz and Roemer (2004) conceptualized limited
access to emotion regulation strategies as a person’s belief that there is little that can be done to
alter one’s mood state after becoming upset. This particular subscale of the DERS has shown
unique links to suicidal ideation compared to the other subscales (e.g., Hatkevich et al., 2019).
For example, in a study of adolescents admitted to an inpatient psychiatric facility, only the
strategies subscale was significantly related to past year suicidal ideation (Hatkevich et al.,
2019). For individuals who perceive they do not have the tools to cope with their emotions, it is
thought that suicidal ideation may be a cognitive problem-solving coping strategy (e.g., Jobes,
2012; Valois et al., 2019). Individuals who perceive themselves to be unable to cope with being
upset may be more likely to cope via suicidal ideation when exposed to weight-based
stigmatization and may relate to the hopelessness subcomponent of the IPT. For individuals who
have PB, TB, and hopelessness about these states changing, they may also feel unable to cope
with negative emotions and may appraise suicide as an escape. The current study did not
examine hopelessness, so such claims must be examined in future research.
The findings should be interpreted within the context of the study limitations. The sample
is from a university population and therefore, may not be generalizable to the entire population
of individuals who are stigmatized for their weight. In addition, the convenience sample was

WEIGHT STIGMA & SUICIDE RISK 19
drawn from a mid-sized, midwestern university, of which, similarly to the population of the area,
the sample was overwhelmingly White and non-Hispanic. There may have been restriction of
range issues for weight-based stigmatization experiences, eating pathology, and suicide risk due
to this being a university sample, as well. Our measure of weight stigma was also based upon
frequency of experiences, versus the impact of these discriminatory experiences or one’s
appraisal of the experiences. Future research needs to investigate whether if these different
angles of weight stigma are related and important to the IPT and/or affect regulation theory. The
study also did not directly test all parts of the IPT, such as capability for suicide or hopelessness.
The study examined eating pathology in general, which covers different types of behaviors. It is
important to replicate and extend the current study and investigate if specific types of eating
pathology may exert an effect on the way the model was proposed. Finally, it is important to
contextualize the current study within the confines of it being cross-sectional and thus that these
mediational analyses are preliminary. Future research will need to be longitudinal to determine
any temporal effects or causality.
The current study contributes to a new line of research investigating the links between
weight stigma and suicide risk and offers some insight into potential mechanisms. The results
may also have real-world implications for clinicians needing to prioritize assessment of suicide
risk and consider weight stigma experiences when working with clients. This may especially be
true if an individual endorses themes of PB, TB, and believes they do not have access to effective
emotion regulation strategies. The information gathered in the current study also points to
possible targets for intervention to reduce a client’s risk. Clinicians could help clients through
healthy processing of weight stigmatization experiences and dismantling the influence of diet
culture upon the client’s life via social justice-oriented frameworks such as Health at Every Size
(Association for Size Diversity & Health, 2020) or weight-neutral approaches (Tylka et al.,

WEIGHT STIGMA & SUICIDE RISK 20
2014). Additionally, clinicians could help clients with reducing emotion dysregulation, such as
with Integrated Cognitive-Affective Therapy (Wonderlich et al., 2013) or Dialectical Behavior
Therapy (Linehan, 1993). Clinicians may want to focus on fostering self-efficacy for the
individual’s emotion regulation tool-belt, based upon our finding that limited access to emotion
regulation strategies was an especially salient form of emotion dysregulation. These ideas need
to be tested and corroborated in clinical samples. It may be that compared with other variables or
with the effects of disorders such as depression, weight stigma may not be as salient of a risk
factor in clinical samples.
In a society that views larger bodies as undesirable and a drain on society (e.g., Hunger,
Smith, et al., 2020), an increasingly acceptable demographic for discrimination (Andreyeva et
al., 2008; Rubino et al., 2020), and has demonstrated increases in implicit bias towards those in
larger bodies as compared to other stigmatized groups (Charlesworth & Banaji, 2019), studies
such as ours provide support for the need to change the treatment of those in larger bodies. In a
recent consensus statement by experts in the fields of weight stigma, public policy and media
were identified as sources that use weight discriminatory stereotypes under the guise of concern
for public health (Rubino et al., 2020). Suicide rates have increased over recent years and it
remains the tenth leading cause of death among most age groups in the US (Haskins, 2019).
Studies such as ours contribute to the growing literature linking weight stigma to suicide and
highlight how incompatible these discriminatory practices are in the quest for increased public
health. Weight stigma contributes to an environment which potentially fosters greater suicide risk
and suggest that dismantling weight stigma may contribute to suicide prevention. Future research
needs to directly investigate the utility of targeting weight stigma for the purposes of suicide
prevention. Public policy that incentivizes weight inclusivity, disincentivizes “healthism,” and
fosters welcoming healthcare environments (Hunger, Smith et al., 2020) may contribute to

WEIGHT STIGMA & SUICIDE RISK 21
minimizing stigma and reducing negative outcomes such as increased suicidality. Overall, the
current study contributes to a literature linking weight stigmatization experiences to a cornucopia
of serious negative outcomes and highlights the need to investigate effective ways to cope with
weight stigma both individually and at a societal level.
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WEIGHT STIGMA & SUICIDE RISK 31
Figure 1. Model of the relationship between weight stigmatization and suicide risk with the
indirect effects of thwarted belongingness and perceived burdensomeness.

WEIGHT STIGMA & SUICIDE RISK 32
Figure 2. (a). Model of the relationship between weight stigmatization and suicide risk with the
indirect effects of emotion dysregulation and eating pathology. (b). Model of the indirect effect
analysis of weight stigmatization on suicide risk by emotion dysregulation subscale.
Figure 3. Model of the relationship between weight stigmatization and suicide risk with the
indirect effects of emotion dysregulation, eating pathology, thwarted belongingness, and
perceived burdensomeness.
Table 1
Descriptive Statistics and Bivariate Correlations

WEIGHT STIGMA & SUICIDE RISK 33
1 2 3 4 5 6
1. Weight Stigmatization -
2. Emotion Dysregulation 0.40** -
3. Eating Pathology 0.57** 0.50** -
4. Perceived Burdensomeness 0.46** 0.53** 0.33** -
5. Thwarted Belongingness 0.33** 0.55** 0.35** 0.68* -
6. Suicide Risk 0.26* 0.40** 0.27* 0.54* 0.30* -
Mean 14.26 82.44 15.29 9.13 19.88 4.10
SD 4.92 20.50 11.90 5.11 10.83 2.17
Observed Range 12-40 46-148 1-59 6-35 8-54 3-13
Possible Range 12-60 36-180 0-112 6-42 7-56 3-18
*p < 0.01; **p < 0.001
Table 2
Indirect effects analysis (model 4) of weight stigma on suicide risk via perceived
burdensomeness and thwarted belongingness.
Path Point Estimate SE 95% CI
Paths a
Weight stigma  Perceived burdensomeness 0.49* 0.08 0.34, 0.65
Weight stigma  Thwarted belongingness 0.74* 0.18 0.39, 1.09
Paths b
Perceived burdensomeness  Suicide Risk 0.26* 0.04 0.17, 0.34
Thwarted belongingness  Suicide Risk -0.03 0.02 -0.06, 0.01
Paths c’
Weight stigma  Suicide Risk 0.01 0.04 -0.06, 0.08
Indirect effect (ab)
Via Perceived burdensomeness 0.13* 0.05 0.04, 0.24
Via Thwarted belongingness -0.02 0.02 -0.06, 0.01
Note. SE = standard error; CI = confidence interval; * p < 0.001
Table 3
Indirect effects analysis (model 4) of weight stigma on suicide risk via emotion dysregulation
and eating pathology.
Path Point Estimate SE 95% CI
Paths a
Weight stigma  Emotion dysregulation 1.90** 0.34 1.23, 2.56
Weight stigma  Eating pathology 1.44** 0.17 1.11, 1.77
Paths b

WEIGHT STIGMA & SUICIDE RISK 34
Emotion dysregulation  Suicide Risk 0.03* 0.01 0.02, 0.05
Eating pathology  Suicide Risk 0.01 0.02 -0.03, 0.04
Paths c’
Weight stigma  Suicide Risk 0.04 0.04 -0.04, 0.13
Indirect effect (ab)
Via Emotion dysregulation 0.06* 0.02 0.03, 0.11
Via Eating pathology 0.01 0.03 -0.04, 0.06
Note. SE = standard error; CI = confidence interval; * p < 0.05; ** p < 0.001
Table 4
Indirect effects analysis (model 4) of weight stigma on suicide risk via emotion dysregulation
subscales.
Path Point Estimate SE 95% CI
Nonacceptance
Paths a0.43** 0.08 0.28, 0.59
Paths b 0.04 0.06 -0.07, 0.16
Goals

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Paths a0.20** 0.07 0.07, 0.34
Paths b -0.07 0.06 -0.19, 0.04
Impulse
Paths a0.30** 0.07 0.17, 0.43
Paths b 0.09 0.06 -0.03, 0.21
Aware
Paths a0.21** 0.08 0.05, 0.36
Paths b -0.04 0.04 -0.13, 0.05
Strategies
Paths a0.51** 0.10 0.31, 0.71
Paths b 0.11* 0.05 0.003, 0.21
Clarity
Paths a0.24** 0.06 0.12, 0.36
Paths b -0.001 0.06 -0.13, 0.13
All subscales
Paths c’ 0.04 0.04 -0.03, 0.12
Note. SE = standard error; CI = confidence interval; * p < 0.05; ** p < 0.01
Table 5
Indirect effects analysis (model 4) of weight stigma on suicide risk via emotion dysregulation,
eating pathology, thwarted belongingness, and perceived burdensomeness.
Path Point Estimate SE 95% CI
Paths a
Weight stigma  Emotion dysregulation 1.90** 0.34 1.23, 2.56
Weight stigma  Eating pathology 1.44** 0.17 1.11, 1.77
Weight stigma  Thwarted belongingness 0.74** 0.18 0.39, 1.09
Weight stigma  Perceived burdensomeness 0.49** 0.08 0.34, 0.65
Paths b
Emotion dysregulation  Suicide Risk 0.02 0.01 -0.001, 0.04
Eating pathology  Suicide Risk 0.02 0.02 -0.01, 0.05
Thwarted belongingness  Suicide Risk -0.04* 0.02 -0.08, -0.003
Perceived burdensomeness  Suicide Risk 0.25** 0.04 0.16, 0.33
Paths c’
Weight stigma  Suicide Risk -0.03 0.04 -0.11, 0.05
Indirect effect (ab)
Via Emotion dysregulation 0.03 0.02 -0.006, 0.08

WEIGHT STIGMA & SUICIDE RISK 36
Via Eating pathology 0.03 0.02 -0.02, 0.08
Via Thwarted belongingness -0.03 0.02 -0.08, 0.004
Via Perceived burdensomeness 0.12* 0.05 0.03, 0.23
Note. SE = standard error; CI = confidence interval; * p < 0.05; ** p < 0.001