I stare at her in disbelief. No one has ever addressed me like that. But I do not have time to react because she carries on:
You will follow a weight-gain meal plan. The goal is two to four pounds a week. Your portions and caloric intake will be increased gradually. You will meet with me on a biweekly basis so I can determine those, and in between you will be closely monitored for symptoms of refeeding syndrome.
Refeeding syndrome. Potentially fatal shifts in fluids and electrolyte levels, like sudden drops of phosphate in the blood, when a malnourished patient is refed. Starving bodies that have starved for too long can quite literally be shocked by food. Muscle weakness, coma, possibly death.
She knows she now has my attention.
The nutritionist continues:
You will be given the chance to choose all your meals once a week. We usually offer our patients two options, but since you’re vegetarian— Vegan,
I try again.
We do not accommodate vegans. Now, as I was saying … Since you’re vegetarian, you will only have one nonmeat option to choose from.
What if I do not like that nonmeat option?
Then you will have a substitute meal like the one you had for dinner yesterday.
What if I do not like the substitute?
I am irritating her, but this is too horrifyingly important for me to let up. She sighs and closes her eyes, and when she opens them again, speaks in a sickly sweet voice I immediately recognize as dangerous:
You don’t know what you like or don’t like, not that it matters at this point.
I beg her pardon?
That smile again. In the same sickly voice, but with an eyebrow lifted, she asks:
How do you take your coffee?
Black. No sugar.
How do you take your tea?
Hot. Green or ginger.
Sugar?
Of course not.
How do you take your eggs?
I do not like eggs.
How do you butter your toast?
I do not butter my toast.
I do not eat butter or toast. No fats or simple carbohydrates.
Milk or dark chocolate?
Neither, thank you.
What do you like to eat?
What do you eat? would have been a simpler question to answer. I eat fruits, apples mostly. Sometimes with a squeeze of lemon. When I want something salty I eat lettuce or cabbage. For a treat: microwave popcorn.
What do you like to eat?
I have not answered her. Apples and popcorn, I suppose. Once upon a time my answer to that question would have been very different. Once upon a time I also would have told her that I ate my eggs scrambled, chocolate dark, toast warm and just barely crisp and golden. No butter but sprinkled with salt.
But now I do not like to eat anything. I eat out of necessity, to silence my hunger and function a while longer.
Apples and popcorn
do the trick. I do not need or want anything else, her horrible bagels and cream cheese.
I would like to order off the menu please. Something healthy and natural, something like— Popcorn?
she interrupts. Her patience and even her fake, thread-thin smile have run out.
You would need to eat thirty-five bags a day, or forty-six point sixty-six medium apples to meet your caloric needs.
She has succeeded, again, in shocking me into silence. I do not understand what she means. Rather, I do not want to understand what she means by “caloric needs.”
Let me explain the refeeding process to you, who seem to know so much about nutrition: A normal body, at rest, needs a thousand calories to survive. Just the basics: heartbeat, breath, blood flow, body temperature.
I already wince at a thousand.
A normal woman of your height and age needs a thousand to fifteen hundred more to carry out the basic active functions of her day: like getting out of bed, going to work. Driving her car, talking on the phone, picking up groceries, walking the dog, hanging her coat up, even watching TV … but you need even more than that.
More? More? Than two thousand calories? More than two thousand five hundred?
Because you’ve been starving and overexercising, you’ve been feeding on your own organs. You have no fat reserves, no period, no calcium in your bones. No estradiol in your bloodstream. In fact, you are less woman now than a two-year-old girl.
She is treating me like that two-year-old girl, the recurring theme of this place. But I have no time to be angry; the nutritionist drops her next bomb:
In order to repair the damage you’ve done, your body needs more energy. More energy means more calories: five hundred more, at least.
I do the math, poorly, in my head. I feel a panic attack coming on.
Two thousand five hundred calories?
I shriek.
At least. Probably more. I have had patients consume up to three thousand five hundred for results.
Three thousand five hundred calories! A day! More food than I consume in four! She is mad, utterly mad.
You need low-volume, high-fat, calorie-dense foods. Believe me, thirty-five bags of popcorn will not fit in that stomach of yours.
I do not even bother to hold back the tears. The time is past for pretense at poise. I cry like that two-year-old girl, terrified and trapped in a body I have no use for.
I do not scream. I hiccup and sob. I tell her to go to hell and that I am done. I am taking my anorexia with me and we are both going home.
If you leave you will die,
she says, indifferent, bringing this conversation to an end. She walks past the plush red chair and opens the door. Our first session is over.
And keep in mind that you have two refusals left before you get the tube.
22
Meal Plan—May 24, 2016
Patient Body Mass Index: 15.1
Normal BMI range: 18.5–24.9
Other symptoms: Bradycardia, arrhythmias, osteopenia, unstable vital signs.
Treatment Objective: Weight gain and restoration of patient BMI to within normal range.
Meal Plan: Patient will consume three meals and three snacks at two-to-three-hour intervals daily.
Initial caloric value set at 2,100 calories per day, to be increased by 250–300 calories every forty-eight hours to seventy-two hours.
Patient will be monitored for symptoms of refeeding syndrome and other medical complications, including but not limited to: heart failure, arrhythmias, respiratory failure, muscle breakdown, sudden death.
Calorie Guidelines (to be revised as needed) Breakfast: 400 calories (to be increased to 800 calories) Lunch: 550 calories (to be increased to 800–1,000 calories) Dinner: 550 calories (to be increased to 800–1,000 calories) Midmorning snack: 200 calories (to be increased to 400 calories) Afternoon snack: 200 calories (to be increased to 400 calories) Evening snack: 200 calories (to be increased to 400 calories) Meal Plan may be complemented by a liquid nutritional supplement to increase calorie density. Value: 350 calories per 8 fl. oz. Liquid supplement must be administered immediately if meals are skipped, refused, or unfinished.
23
I am back in community space before 10:00 A.M. I try to breathe down the storm in my chest; I have cried enough for today, for the week, and it is only Tuesday.
Only two days, and I am already suffocating in this place, from being told when and what to eat, when to use the bathroom and when to go to sleep. Two days ago I was a grown woman. Now I have two refusals left. I must have signed my independence off on one of those admission forms.
All the women who come here do, with the keys, phones, and tweezers they hand in. They also sign off their lives, careers, families, closets of dresses and high heels. Stripped of the energy to process anything beyond heartbeat, breathing, some body heat, they then devolve into little girls throwing tantrums at breakfast tables.
What a mess and first impression I made this morning in front of the other girls. Most do not even know my name yet. They are now out on their morning walk.
I must apologize as soon as they return. The front door opens and they enter.
Emm comes straight to me and in her professional voice, asks if she can have a word.