It is extremely difficult to draw general conclusions about the efficacy of specific treatment options for AN. There are few controlled clinical trials and their quality is generally poor. These guidelines necessarily rely largely upon expert opinion and uncontrolled trials. A multidimensional approach is recommended. Medical manifestations of the illness need to be addressed and any physical harm halted and reversed. Weight restoration is essential in treatment, but insufficient evidence is available for any single approach. A lenient approach is likely to be more acceptable to patients than a punitive one and less likely to impair self-esteem. Dealing with the psychiatric problems is not simple and much controversy remains. For patients with less severe AN who do not require in-patient treatment, out-patient or day-patient treatment may be suitable, but this decision will depend on availability of such services. Family therapy is a valuable part of treatment, particularly for children and adolescents, but no particular approach emerges as superior to any other. Dietary advice should be included in all treatment programs. Cognitive behaviour therapy or other psychotherapies are likely to be helpful. Antidepressants have a role in patients with depressive symptoms and olanzapine may be useful in attenuating hyperactivity.

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Thank you for the opportunity to respond to Lorraine Bell's letter concerning our article 'Anorexia B Deux: An ominous sign for recovery'. We wish to highlight two important points. First, the reasons for adopting a vegetarian diet are always clarified during the patient's initial assessment with the resident dietitian on our team and verified where appropriate with the parents. Invariably we find that only a small proportion of anorexic patients claim to be vegetarian for religious or humanitarian reasons or were vegetarian before the onset of their illness. If vegetarianism has predated anorexia, patients are always allowed to continue as such unless they request otherwise. Second, for the anorexic patient red meat is often equated with fat which must be avoided. We have found in most cases chicken and fish are still eaten and no attempt has been made to replace red meat with vegetable proteins such as soy beans and lentils.We have ample evidence for vegetarianism frequently being a sign of anorexia nervosa from both our clinical experience and from a retrospective study of a large sample of anorexic patients conducted by two of the co-authors (O'Connor et al., 1987). O'Connor et al. found that 63 (54.3 per cent) of 116 anorexic patients were avoiding red meat. O f those, only four (6.3 per cent) were true vegetarians, that is, red meat avoidance predated the onset of the anorexia nervosa. Of the remaining 59 patients, 25 (42.4 per cent) continued to avoid red meat by the end of treatment.Similarly, vegetarianism and anorexia nervosa has been the focus of an investigation by Kadambari et al. (1986).Our ongoing clinical experience points to the hazards of vegetarianism in anorexia nervosa, such as, iron-deficiency anaemia associated with red meat avoidance.O'Connor et al. also found that red meat avoidance was associated with a longer duration of anorexia nervosa and a lower BMI during the course of the illness.Although vegetarianism is not invariably a symptom of anorexia, it often is. We believe it would be negligent not to address the issues of vegetarianism and red meat avoidance with anorexic patients and their families as part of their assessment and nutritional rehabilitation.

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