Scene:  hospital bedside, the doctor is making rounds.  The patient, a 16 year old boy, is in his hospital bed having been admitted earlier that day.  His mother is next to him.  In tears.  He is angry and tearful himself.  He is well groomed, clean and tidy, good-looking but very, very thin with obvious muscle-wasting.  His heart rate, although he is angry, is in the 40’s, at night it drops to the low 30’s.  He is too orthostatic to stand.

“Jacob,” the doctor says, “I’m here to answer your questions.”

Jacob’s eyes fill with tears, his chin quivers although he is making a large effort to control his emotions and clearly hates crying in front of people.

“I hate this place!  I hate it!  Everyone treats me like I have anorexia and I don’t!  I’m just an athlete.  I’m just an athlete.  Can’t you understand that?”

“I don’t know whether you have anorexia nervosa or not, Jacob.  Only time will tell.  What I do know is that you have lost so much weight that your heart muscle has weakened and you are having trouble standing.”

“I don’t have anorexia! OK?  I eat plenty. I don’t count calories, I don’t even know how.  I never pay attention to calories. OK?”

“Maybe you don’t.  Help me understand…what exactly do you eat for breakfast each day?”

“What do you mean?  It’s different every day.  I never count calories, if that’s what you mean.”

“No, I mean what exactly do you eat on a typical day?”

“OK.  I usually have a yogurt and lots of fruit and maybe some granola.”

“What kind of yogurt?” the doctor turns to his mother  “Do you know, Mom?”  

“I’m not really sure, ” she says, clearly afraid to anger her son and tormented by his sorrow, “He does a lot of the grocery shopping.”

“It’s fat free, the usual kind.”  Jacob offers. “And I have some granola too.”

“Ok, great,” the doctor says, “Some granola.  About how much would you say?”

“I dunno….a handful?”

“Ok.  And for lunch…do you pack your lunch or eat school food?”

“I pack my lunch. Two pieces of bread, some turkey, some lettuce, lots of salsa.  Lots.”

“And what do you drink?”

“Water.  Aren’t you supposed to drink lots of water?”

“Do you have a snack before dinner?”

“Sometimes.  An apple or grapes or even a Protein Bar.”

“What about dinner?  Do you think you get enough calories for an athlete with what you told me so far? And how much do you work out these days?”

Jacob shifts in his bed; he has no fat over his back and buttocks and staying in bed is very uncomfortable.

“I told you, I don’t count calories.  Only anorexics do that.  I eat what my parents eat.  I’m on the track team and there’s lots of guys skinnier than me.  I run six miles a day, at least;  I do cardio workouts in the gym for 45 minutes….. it’s summer so I swim laps….I lift weights three times a week…. Our coach tells us we need to build strength too.”

The doctor nods,  “Yes, I understand you love sports.”

“I don’t just love sports,” his eyes fill with tears, “They’re my life!  And you are taking it away from me.  I don’t have anorexia, I’m just trying to get healthy. You guys just make an assumption and treat me like everyone else. One size fits all.  I’m different!  I’m not like those other patients!  I’m not!  I don’t count calories and I eat, just like I told you….I even eat ice cream.”

The doctor looks at Mom for confirmation.  She nods: “Low fat ice cream or fat free frozen yogurt, he does.”

Jacob dries his eyes with a tissue and takes a deep breath, exhausted from his outburst:  “I have one more question.  Can I chew gum?”

“He really likes gum,” his mother says, “he chews two packs a day.”

The doctor nods, “You can have sugared gum, three pieces a day, Jacob.  That ok?”

His eyes flash anger,  “No it’s not! I’ll just skip the gum then….. I want sugarless!”

“Why Jacob?” the doctor asks softly, “……because sugar free gum has no calories?”

“No!” he shouts, “No!  It does too have calories…it has five calories!”