Division of Clinical Therapeutics, The New York State Psychiatric Institute;
Department of Psychiatry, Columbia University College of Physicians and Surgeons;
Tom Hildebrandt
Eating and Weight Disorders Program, Mount Sinai School of Medicine
G. Terence Wilson
Graduate School of Applied and Professional Psychology, Rutgers, The State University of New Jersey
Denise E. Wilfley
Department of Psychiatry, Washington University School of Medicine
W. Stewart Agras
Department of Psychiatry, Stanford University
Acknowledgement: Portions of this article were presented at the annual meeting of the Academy for Eating Disorders, Seattle, Washington, May 2008. This research was supported in part by National Institute of Mental Health (NIMH) Grants 5R01MH063862-05, 5R01MH064153-06, and 5R01MH063863-05 awarded to G. Terence Wilson, Denise E. Wilfley, and W. Stewart Agras, respectively. Robyn Sysko is supported, in part, by National Institute of Diabetes and Digestive and Kidney Diseases Grant DK088532-01A1. Tom Hildebrandt is supported, in part, by National Institute on Drug Abuse Grant DA024043-01. Denise E. Wilfley is supported, in part, by NIMH Grant K24 MH070446.
The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV;
Although some critics have questioned the validity of the BED diagnosis (e.g.,
Increasingly, statistical methods, such as latent class analysis (LCA), are used to examine diagnostic heterogeneity and the appropriateness of DSM–IV diagnoses. LCA investigates population heterogeneity using categorical latent variables. The assumption of this type of analysis is the existence of distinct homogenous subgroups, which when grouped together, yield a heterogeneous population. For example, if individuals with two different types of eating disorder were in the same population, LCA would, in theory, separate these groups on the basis of their pattern of symptoms. In previous studies investigating the eating disorder diagnoses more broadly, LCA has evaluated the validity of the current DSM–IV classification scheme, and research using this type of analysis generally supports existing categorical models of eating disorder psychopathology (e.g.,
Three studies have used cluster analysis, another statistical method for subtyping, with samples of individuals with BED on the basis of dietary restraint and negative affect (
Latent transition analysis is a longitudinal extension of LCA and a special type of Markov chain modeling (
In the current study, LCA was used to provide an empirical test of the existence of heterogeneity within the population of overweight or obese individuals all meeting strict DSM–IV criteria for BED. Variables in the LCA were chosen on the basis of the following: previous research (e.g., negative affect;
The application of LCA to evaluate subgroups within a large treatment-seeking sample of overweight or obese patients with BED, and latent transition analysis to examine whether observed latent classes predict treatment outcome, represents a novel application of these statistical procedures. The findings may help suggest potentially useful diagnostic specifiers within the BED diagnosis or means for matching specific treatments to particular subgroups in the larger population.
A detailed description of the multisite treatment trial upon which this study is based has been reported elsewhere (
Patients were randomly assigned to one of three treatment conditions: IPT (n = 75), BWL (n = 64), or CBTgsh (n = 66). The IPT condition was based on the treatment as originally developed for depression (
Participants completed a baseline assessment battery, including both interviews and self-report questionnaires, and were subsequently randomly assigned to one of the three treatment conditions. Demographic characteristics (e.g., age, gender) were obtained by interview. The Structured Clinical Interview for DSM–IV (
Participants also completed the Eating Disorder Examination Version 14.3 (
Other assessment data obtained at the baseline evaluation included a measure of depressive symptoms and negative affect from the Beck Depression Inventory (
Baseline LCA
LCA
In the current study, Mplus Version 4.20 (
The primary indicators used in the LCA—which included baseline measures of eating pathology, weight, physical activity, and depressive symptoms—were chosen on the basis of previous research or clinical relevance. The Eating Disorder Examination variables consisted of the Restraint, Shape Concern, and Weight Concern subscales; an item assessing dietary restraint outside of bulimic episodes; the number of objective bulimic episodes, subjective bulimic episodes, and objective overeating episodes over the 28 days prior to the baseline assessment; the five features associated with binge eating; distress about binge eating; and compensatory behaviors (vomiting, laxative abuse, diuretic use, exercise). In addition, baseline BMI (kg/m
Posttreatment LCA
A second LCA of the posttreatment Eating Disorder Examination outcome data established a treatment responder group using outcome variables as indicators (objective bulimic episodes, subjective bulimic episodes, objective overeating episodes, BMI, Weight Concern, Shape Concern, Beck Depression Inventory, Restraint). The posttreatment LCA model was constructed in a manner identical to the baseline LCA described above, with the exception that a zero class was included in the model. As is typical with behavioral data and particularly with studies of active treatment for BED, such as cognitive behavioral or interpersonal therapies or guided self-help, relatively high rates of abstinence from binge eating are observed at the end of treatment (e.g., 46%,
Latent transition analysis
To test the predictive validity of the baseline LCA model, we used a special form of a latent Markov model known as a latent transition analysis (
Data screening for baseline and posttreatment latent class analyses
Prior to conducting the analyses, box-plots and distributions (i.e., skewness and kurtosis) for the indicators (objective bulimic episodes, subjective bulimic episodes, and objective overeating episodes) were examined, and two outliers were identified (both outliers were greater than 15 standard deviations outside the mean for objective bulimic episodes). Although analyses with and without these outliers yielded similar results, the data reported below do not include these outlier cases.
Missing data
For the LCA and latent transition models, missing data were replaced using an expectation maximization algorithm and the maximum likelihood estimator under the assumptions of missing at random (
Covariates
Several background variables of interest were evaluated in both the baseline latent class and latent transition models, including age, gender, and presence of a prior diagnosis of anorexia nervosa or bulimia nervosa. From the potential subtypes described by
Conditional latent transition analysis models
Additional latent transition analysis models tested possible effects of the treatment on the transition between latent classes at baseline and treatment response classes. A base latent transition analysis model was estimated with transition probabilities between baseline latent class and treatment response (posttreatment latent class), and the model was constrained such that the transition probabilities were equivalent across treatment groups. A second model was subsequently calculated with these transition probabilities free to vary across levels of the covariate (e.g., across treatments), and chi-square difference tests were used to evaluate the nested model. As the number of cells used to estimate the transitions between categories within treatments was large (24 separate cells), some treatment effects were set to extremes (logit of 15 or −15) in the conditional latent transition analysis model because of low/high transition probabilities for specific patterns of transition (e.g., Class 4 transition to the responder Class 2, conditional on treatment). This was done to improve model convergence and to aid in interpretation of treatment effects.
The best fitting model estimated means and standard errors for the primary indicators and predictors (gender, age, and past eating disorder diagnosis) used in the baseline LCA are listed in
In comparison with the other three latent classes, Class 1 included the largest percentage of individuals diagnosed with an eating disorder in the past, the lowest average BMI, and the most activity as measured by the International Physical Activity Questionnaire. These characteristics suggest that participants in Class 1 may have migrated from another eating disorder into the BED classification and continue to endorse symptoms similar to those observed in individuals with bulimia nervosa (e.g., high levels of activity, notable shape and weight concerns). Individuals belonging to Class 2, in comparison with the other latent classes, demonstrated the most binge eating pathology (e.g., highest average objective bulimic episodes and subjective bulimic episodes), greatest shape and weight concerns, greatest distress about binge eating episodes, the largest percent of compensatory behaviors, and the highest scores on the Beck Depression Inventory. Thus, this class appears to include individuals who exhibit features of both BED and bulimia nervosa, nonpurging type, which is consistent with a “mixed” presentation. Participants in Class 3 reported the lowest percentage of past eating disorder diagnosis and are therefore less likely to have migrated from another eating disorder. In addition, Class 3 individuals endorsed symptom frequencies for objective bulimic episodes and subjective bulimic episodes that are comparable with Class 2, but higher than both other classes, and they exhibited lower levels of exercise or current compensation in comparison with Classes 1 or 2. Finally, Class 4 had the highest BMI, the lowest number of objective bulimic episodes and subjective bulimic episodes, the most objective overeating episodes—suggesting a pattern of chaotic eating—and a complete absence of compensatory behaviors compared with the other latent classes.
To illustrate the frequencies of class membership, we assigned participants to a latent class on the basis of the highest model estimated probability for class membership.
Initially, two- to five-class models were estimated with parameters free to vary. The pattern suggested that a two-class solution provided the best fit, but the models required a large number of iterations to terminate, and some models were difficult to interpret (e.g., classes with very small number of probable participants). We subsequently included a zero class and reestimated the LCA models. As described in
To evaluate the predictive validity of baseline latent class on treatment outcome, we calculated both unconditional (without a covariate) and conditional (with a covariate) latent transition analyses. The unconditional model was a good fit for the data (df = 103, loglikelihood = −7,820.20, BIC = 15,880.56, AIC = 16,248.33, entropy = .890), although several parameters were fixed to extremes to aid with model termination. Specifically, for the individuals in Classes 1 and 4, the transition parameters were fixed to a logit of −15, as a nearly 100% treatment response was observed among these classes. A conditional latent transition analysis model examined the effects of treatment, in which treatment (IPT, BWL, CBTgsh) was evaluated as a categorical moderator. The conditional latent transition analysis model, in which the probability of transitioning from one baseline latent class into posttreatment latent class was equal across treatments, did not fit the data as well as a model in which transition probabilities were free to vary across classes, χ
The results reported in
The first aim of this study was to assess the presence of distinct subgroups among overweight or obese individuals diagnosed with DSM–IV BED, as suggested by
Previous research examining heterogeneity in samples of patients with eating disorders (e.g.,
In the subsequent latent transition analysis evaluating the second aim of this study, class membership was identified as an important moderator of treatment response, or the likelihood of achieving abstinence from binge eating and overeating over the prior month. Classes 1 and 4 experienced a 100% response to treatment, regardless of the type of treatment received, but Class 2 had a higher probability of achieving abstinence with IPT, and Class 3 had a greater response to CBTgsh. The superiority of the four latent class model and the differential treatment response among groups of patients with BED indicate that the DSM–IV criteria may not sufficiently address the heterogeneity within this diagnosis, which could contribute to discrepant findings in the literature about this population. For example, studies indicating that patients with BED fail to show a specific response to different treatments (see
The current study suggests that both shape and weight concerns were strongly associated with subgroup. Recent studies by Grilo and colleagues (
Broader clinical recommendations can also be made from the findings of the current study, particularly when considering the differential short-term response to treatment observed in Classes 2 and 3, the two largest latent classes. This result is surprising as a substantial proportion of participants were abstinent from binge eating or overeating posttreatment (60%), and no clear advantage was found (a) for any treatment when the three treatments were compared over 24 weeks without considering latent class membership (
There are several limitations in the design of this study. Only one sample of treatment-seeking patients with BED was used for the analyses, the sample was restricted to individuals meeting a strict definition (DSM–IV BED), and the sample included primarily women and Caucasian participants. The analyses should be replicated in other existing large data sets from BED treatment studies to determine the extent to which similar findings can be observed. Replication would increase confidence in the four latent classes observed at baseline and could also address questions about the stability of the latent classes over time. In addition, our two-class posttreatment latent class model utilized a zero class, an approach that does not account for measurement error; however, this approach is arguably more conservative because all members in this class are required to be abstinent. Finally, for individuals in Class 2, who reported greater psychopathology, it is possible that the differential treatment response to IPT may have resulted from greater therapeutic contact than in CBTgsh. However, as IPT and BWL provided equivalent amounts of treatment, and BWL was not found to be a superior for any of the subgroups, a more likely interpretation for our findings relates to the content of the treatments. Although there are certainly limitations to the current study, there were also specific advantages to the methodology used, as latent transition analysis allows for the modeling of changes in symptoms over time and can appropriately examine treatment response, even when abstinence rates are high.
The results of this study, particularly the use of LCA, offer a novel approach to identifying the individuals most likely to respond to IPT and CBTgsh, and they indicate that treatment matching, or offering different treatments to specific patient groups, is possible for patients with BED. Additional studies identifying moderators of treatment response for patients with BED will likely enhance the efficacy of existing treatments and assist in treatment development (
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Submitted: June 4, 2009 Revised: January 12, 2010 Accepted: March 18, 2010