To the Editor: We are writing in response to the editorial of Ben-Tovim et al.1 Although we agree that more research into treatment efficacy in eating disorders is needed, we believe that the study to which reference is made2 is seriously flawed. The study should not be presumed to provide evidence about the effect of treatment on outcome, particularly as the majority of patients studied received no treatment. The high death rate (3/95 [3.2%] among patients with anorexia nervosa and 2/37 [5.4%] among patients with "eating disorders not otherwise specified") in such mildly ill patients (few of whom would have warranted hospitalisation on the basis of their weight) approximates that of seriously emaciated patients in longer-term studies of treatment outcome3,4 and could more properly be said to illustrate the results of having no treatment or inadequate treatment.

Exactly what constituted specialised treatment is never actually described in the original article,2 in which "extended inpatient treatment" is defined as treatment lasting more than two weeks and "extended outpatient treatment" as three or more visits. Thus, the so-called "resource intensive treatment" the authors refer to would not necessarily represent even adequate management of these conditions.

In our own 6–10-year outcome study5,6 cited by the authors, 61 emaciated patients with anorexia nervosa received, on average, 11 weeks of inpatient treatment consisting of nutritional rehabilitation and psychotherapy. Only one patient died (of suicide) and, of the patients fully assessed, 41/50 (82%) had a good or intermediate outcome. The degree of weight restoration achieved by the end of treatment correlated with the degree of osteoporosis 10 years later.7

In other studies, duration of illness and early intervention have been shown to significantly influence outcome.4 This contrasts with the findings of Ben-Tovim et al,2 which may have been skewed by an unusual level of chronicity in the study group. A recent study of 69 patients with eating disorders treated in our own multidisciplinary program showed that, on 12–18-month follow-up, 48/69 (70%) had improved and 34/69 (49%) no longer had an eating disorder diagnosis. Mean levels of all but one of the major behavioural and psychological features rated by the EEE-C (Eating and Exercise Examination by Computer) instrument8 were significantly reduced.

The advice given by Ben-Tovim and colleagues to the parents of the hypothetical 15-year-old girl with anorexia nervosa is regrettably nihilistic and, if based on their Lancet study,2 not founded on sound or generalisable evidence. Parents should be referred to a program for which good outcomes have been demonstrated, treatment accords with published guidelines, the clinicians are suitably experienced, and in which early intervention is the aim.4