Few patients will take one's word for it that the slightest deviation from the diet has under HCG disastrous results as far as the weight is concerned. This extreme sensitivity has the advantage that the smallest error is immediately detectable at the daily weighing but most patients have to make the experience before they will believe it.
Persons in high official positions such as embassy personnel, politicians, senior executives, etc., who are obliged to attend social functions to which they cannot bring their meager meal must be told beforehand that an official dinner will cost them the loss of about three days treatment, however careful they are and in spite of a friendly and would-be cooperative host. We generally advise them to avoid all-round embarrassment, the almost inevitable turn of conversation to their weight problem and the outpouring of lay counsel from their table partners by not letting it be known that they are under treatment. They should take dainty servings of everything, hide what they can under the cutlery and book the gain which may take three days to get rid of as one of the sacrifices which their profession entails. Allowing three days for their correction, such incidents do not jeopardize the treatment, provided they do not occur all too frequently in which case treatment should be postponed to a socially more peaceful season.
Vitamins and Anemia
Sooner or later most patients express a fear that they may be running out of vitamins or that the restricted diet may make them anemic. On this score the physician can confidently relieve their apprehension by explaining that every time they lose a pound of fatty tissue, which they do almost daily, only the actual fat is burned up; all the vitamins, the proteins, the blood, and the minerals which this tissue contains in abundance are fed back into the body. Actually, a low blood count not due to any serious disorder of the blood forming tissues improves during treatment, and we have never encountered a significant protein deficiency nor signs of a lack of vitamins in patients who are dieting regularly.
The First Days of Treatment
On the day of the third injection it is almost routine to hear two remarks. One is: “You know, Doctor, I'm sure it's only psychological, but I already feel quite different”. So common is this remark, even from very skeptical patients that we hesitate to accept the psychological interpretation. The other typical remark is: “Now that I have been allowed to eat anything I want, I can't get it down. Since yesterday I feel like a stuffed pig. Food just doesn't seem to interest me any more, and I am longing to get on with your diet”. Many patients notice that they are passing more urine and that the swelling in their ankles is less even before they start dieting.
On the day of the fourth injection most patients declare that they are feeling fine. They have usually lost two pounds or more, some say they feel a bit empty but hasten to explain that this does not amount to hunger. Some complain of a mild headache of which they have been forewarned and for which they have been given permission to take aspirin.
During the second and third day of dieting - that is, the fifth and sixth injection-these minor complaints improve while the weight continues to drop at about double the usually overall average of almost one pound per day, so that a moderately severe case may by the fourth day of dieting have lost as much as 8- 10 lbs.
It is usually at this point that a difference appears between those patients who have literally eaten to capacity during the first two days of treatment and those who have not. The former feel remarkably well; they have no hunger, nor do they feel tempted when others eat normally at the same table. They feel lighter, more clear-headed and notice a desire to move quite contrary to their previous lethargy. Those who have disregarded the advice to eat to capacity continue to have minor discomforts and do not have the same euphoric sense of well-being until about a week later. It seems that their normal fat reserves require that much more time before they are fully stocked.
Fluctuations in weight loss
After the fourth or fifth day of dieting the daily loss of weight begins to decrease to one pound or somewhat less per day, and there is a smaller urinary output. Men often continue to lose regularly at that rate, but women are more irregular in spite of faultless dieting. There may be no drop at all for two or three days and then a sudden loss which reestablishes the normal average. These fluctuations are entirely due to variations in the retention and elimination of water, which are more marked in women than in men.
The weight registered by the scale is determined by two processes not necessarily synchronized. Under the influence of HCG, fat is being extracted from the cells, in which it is stored in the fatty tissue. When these cells are empty and therefore serve no purpose, the body breaks down the cellular structure and absorbs it, but breaking up of useless cells, connective tissue, blood vessels, etc., may lag behind the process of fat-extraction. When this happens the body appears to replace some of the extracted fat with water which is retained for this purpose. As water is heavier than fat the scales may show no loss of weight, although sufficient fat has actually been consumed to make up for the deficit in the 500-Calorie diet. When then such tissue is finally broken down, the water is liberated and there is a sudden flood of urine and a marked loss of weight. This simple interpretation of what is really an extremely complex mechanism is the one we give those patients who want to know why it is that on certain days they do not lose, though they have committed no dietary error.
Patients who have previously regularly used diuretics as a method of reducing, lose fat during the first two or three weeks of treatment which shows in their measurements, but the scale may show little or no loss because they are replacing the normal water content of their body which has been dehydrated. Diuretics should never be used for reducing.
Interruptions of Weight Loss
We distinguish four types of interruption in the regular daily loss. The first is the one that has already been mentioned in which the weight stays stationary for a day or two, and this occurs, particularly towards the end of a course, in almost every case.
The second type of interruption we call a “plateau”. A plateau lasts 4-6 days and frequently occurs during the second half of a full course, particularly in patients that have been doing well and whose overall average of nearly a pound per effective injection has been maintained. Those who are losing more than the average all have a plateau sooner or later. A plateau always corrects, itself, but many patients who have become accustomed to a regular daily loss get unnecessarily worried and begin to fret. No amount of explanation convinces them that a plateau does not mean that they are no longer responding normally to treatment.
In such cases we consider it permissible, for purely psychological reasons, to break up the plateau. This can be done in two ways. One is a so-called “apple day”. An apple-day begins at lunch and continues until just before lunch of the following day. The patients are given six large apples and are told to eat one whenever they feel the desire though six apples is the maximum allowed. During an apple-day no other food or liquids except plain water are allowed and of water they may only drink just enough to quench an uncomfortable thirst if eating an apple still leaves them thirsty. Most patients feel no need for water and are quite happy with their six apples. Needless to say, an apple-day may never be given on the day on which there is no injection. The apple-day produces a gratifying loss of weight on the following day, chiefly due to the elimination of water. This water is not regained when the patients resume their normal 500-Calorie diet at lunch, and on the following days they continue to lose weight satisfactorily.
The other way to break up a plateau is by giving a non-mercurial diuretic for one day. This is simpler for the patient but we prefer the apple-day as we sometimes find that though the diuretic is very effective on the following day it may take two to three days before the normal daily reduction is resumed, throwing the patient into a new fit of despair. It is useless to give either an apple-day or a diuretic unless the weight has been stationary for at least four days without any dietary error having been committed.
Reaching a Former Level
The third type of interruption in the regular loss of weight may last much longer - ten days to two weeks. Fortunately, it is rare and only occurs in very advanced cases, and then hardly ever during the first course of treatment. It is seen only in those patients who during some period of their lives have maintained a certain fixed degree of obesity for ten years or more and have then at some time rapidly increased beyond that weight. When then in the course of treatment the former level is reached, it may take two weeks of no loss, in spite of HCG and diet, before further reduction is normally resumed.
The fourth type of interruption is the one which often occurs a few days before and during the menstrual period and in some women at the time of ovulation. It must also be mentioned that when a woman becomes pregnant during treatment - and this is by no means uncommon - she at once ceases to lose weight. An unexplained arrest of reduction has on several occasions raised our suspicion before the first period was missed. If in such cases, menstruation is delayed, we stop injecting and do a precipitation test five days later. No pregnancy test should be carried out earlier than five days after the last injection, as otherwise the HCG may give a false positive result.
Oral contraceptives may be used during treatment.
Any interruption of the normal loss of weight which does not fit perfectly into one of those categories is always due to some possibly very minor dietary error. Similarly, any gain of more than 100 grams is invariably the result of some transgression or mistake, unless it happens on or about the day of ovulation or during the three days preceding the onset of menstruation, in which case it is ignored. In all other cases the reason for the gain must be established at once.
The patient who frankly admits that he has stepped out of his regimen when told that something has gone wrong is no problem. He is always surprised at being found out, because unless he has seen this himself he will not believe that a salted almond, a couple of potato chips, a glass of tomato juice or an extra orange will bring about a definite increase in his weight on the following day.
Very often he wants to know why extra food weighing one ounce should increase his weight by six ounces. We explain this in the following way: Under the influence of HCG the blood is saturated with food and the blood volume has adapted itself so that it can only just accommodate the 500 Calories which come in from the intestinal tract in the course of the day. Any additional income, however little this may be, cannot be accommodated and the blood is therefore forced to increase its volume sufficiently to hold the extra food, which it can only do in a very diluted form. Thus it is not the weight of what is eaten that plays the determining role but rather the amount of water which the body must retain to accommodate this food.
This can be illustrated by mentioning the case of salt. In order to hold one teaspoonful of salt the body requires one liter of water, as it cannot accommodate salt in any higher concentration. Thus, if a person eats one teaspoonfull of salt his weight will go up by more than two pounds as soon as this salt is absorbed from his intestine.
To this explanation many patients reply: Well, if I put on that much every time I eat a little extra, how can I hold my weight after the treatment? It must therefore be made clear that this only happens as long as they are under HCG. When treatment is over, the blood is no longer saturated and can easily accommodate extra food without having to increase its volume. Here again the professional reader will be aware that this interpretation is a simplification of an extremely intricate physiological process which actually accounts for the phenomenon.
Salt and Reducing
While we are on the subject of salt, I can take this opportunity to explain that we make no restriction in the use of salt and insist that the patients drink large quantities of water throughout the treatment. We are out to reduce abnormal fat and are not in the least interested in such illusory weight losses as can be achieved by depriving the body of salt and by desiccating it. Though we allow the free use of salt, the daily amount taken should be roughly the same, as a sudden increase will of course be followed by a corresponding increase in weight as shown by the scale. An increase in the intake of salt is one of the most common causes for an increase in weight from one day to the next. Such an increase can be ignored, provided it is accounted for. It in no way influences the regular loss of fat.
Patients are usually hard to convince that the amount of water they retain has nothing to do with the amount of water they drink. When the body is forced to retain water, it will do this at all costs. If the fluid intake is insufficient to provide all the water required, the body withholds water from the kidneys and the urine becomes scanty and highly concentrated, imposing a certain strain on the kidneys. If that is insufficient, excessive water will be with-drawn from the intestinal tract, with the result that the feces become hard and dry. On the other hand if a patient drinks more than his body requires, the surplus is promptly and easily eliminated. Trying to prevent the body from retaining water by drinking less is therefore not only futile but even harmful.
An excess of water keeps the feces soft, and that is very important in the obese, who commonly suffer from constipation and a spastic colon. While a patient is under treatment we never permit the use of any kind of laxative taken by mouth. We explain that owing to the restricted diet it is perfectly satisfactory and normal to have an evacuation of the bowel only once every three to four days and that, provided plenty of fluids are taken, this never leads to any disturbance. Only in those patients who begin to fret after four days do we allow the use of a suppository. Patients who observe this rule find that after treatment they have a perfectly normal bowel action and this delights many of them almost as much as their loss of weight.
Investigating Dietary Errors
When the reason for a slight gain in weight is not immediately evident, it is necessary to investigate further. A patient who is unaware of having committed an error or is unwilling to admit a mistake protests indignantly when told he has done something he ought not to have done. In that atmosphere no fruitful investigation can be conducted; so we calmly explain that we are not accusing him of anything but that we know for certain from our not inconsiderable experience that something has gone wrong and that we must now sit down quietly together and try and find out what it was. Once the patient realizes that it is in his own interest that he play an active and not merely a passive role in this search, the reason for the setback is almost invariably discovered. Having been through hundreds of such sessions, we are nearly always able to distinguish the deliberate liar from the patient who is merely fooling himself or is really unaware of having erred.
Liars and Fools
When we see obese patients there are generally two of us present in order to speed up routine handling. Thus when we have to investigate a rise in weight, a glance is sufficient to make sure that we agree or disagree. If after a few questions we both feel reasonably sure that the patient is deliberately lying, we tell him that this is our opinion and warn him that unless he comes clean we may refuse further treatment. The way he reacts to this furnishes additional proof whether we are on the right track or not we now very rarely make a mistake.
If the patient breaks down and confesses, we melt and are all forgiveness and treatment proceeds. Yet if such performances have to be repeated more than two or three times, we refuse further treatment. This happens in less than 1% of our cases. If the patient is stubborn and will not admit what he has been up to, we usually give him one more chance and continue treatment even though we have been unable to find the reason for his gain. In many such cases there is no repetition, and frequently the patient does then confess a few days later after he has thought things over.
The patient who is fooling himself is the one who has committed some trifling, offense against the rules but who has been able to convince himself that this is of no importance and cannot possibly account for the gain in weight. Women seem particularly prone to getting themselves entangled in such delusions. On the other hand, it does frequently happen that a patient will in the midst of a conversation unthinkingly spear an olive or forget that he has already eaten his breadstick.
A mother preparing food for the family may out of sheer habit forget that she must not taste the sauce to see whether it needs more salt. Sometimes a rich maiden aunt cannot be offended by refusing a cup of tea into which she has put two teaspoons of sugar, thoughtfully remembering the patient's taste from previous occasions. Such incidents are legion and are usually confessed without hesitation, but some patients seem genuinely able to forget these lapses and remember them with a visible shock only after insistent questioning.
In these cases we go carefully over the day. Sometimes the patient has been invited to a meal or gone to a restaurant, naively believing that the food has actually been prepared exactly according to instructions. They will say: “Yes, now that I come to think of it the steak did seem a bit bigger than the one I have at home, and it did taste better; maybe there was a little fat on it, though I specially told them to cut it all away”. Sometimes the breadsticks were broken and a few fragments eaten, and “Maybe they were a little more than one”. It is not uncommon for patients to place too much reliance on their memory of the diet-sheet and start eating carrots, beans or peas and then to seem genuinely surprised when their attention is called to the fact that these are forbidden, as they have not been listed.
When no dietary error is elicited we turn to cosmetics. Most women find it hard to believe that fats, oils, creams and ointments applied to the skin are absorbed and interfere with weight reduction by HCG just as if they had been eaten. This almost incredible sensitivity to even such very minor increases in nutritional intake is a peculiar feature of the HCG method. For instance, we find that persons who habitually handle organic fats, such as workers in beauty parlors, masseurs, butchers, etc. never show what we consider a satisfactory loss of weight unless they can avoid fat coming into contact with their skin.
The point is so important that I will illustrate it with two cases. A lady who was cooperating perfectly suddenly increased half a pound. Careful questioning brought nothing to light. She had certainly made no dietary error nor had she used any kind of face cream, and she was already in the menopause. As we felt that we could trust her implicitly, we left the question suspended. Yet
just as she was about to leave the consulting room she suddenly stopped, turned and snapped her fingers. “I've got it,” she said. This is what had happened : She had bought herself a new set of make-up pots and bottles and, using her fingers, had transferred her large assortment of cosmetics to the new containers in anticipation of the day she would be able to use them again after her treatment.
The other case concerns a man who impressed us as being very conscientious. He was about 20 lbs. overweight but did not lose satisfactorily from the onset of treatment. Again and again we tried to find the reason but with no success, until one day he said:“I never told you this, but I have a glass eye. In fact, I have a whole set of them. I frequently change them, and every time I do that I put a special ointment in my eyesocket.. Do you think that could have anything to do with it?” As we thought just that, we asked him to stop using this ointment, and from that day on his weight-loss was regular.
We are particularly averse to those modern cosmetics which contain hormones, as any interference with endocrine regulations during treatment must be absolutely avoided. Many women whose skin has in the course of years become adjusted to the use of fat containing cosmetics find that their skin gets dry as soon as they stop using them. In such cases we permit the use of plain mineral oil, which has no nutritional value. On the other hand, mineral oil should not be used in preparing the food, first because of its undesirable laxative quality, and second because it absorbs some fat-soluble vitamins, which are then lost in the stool. We do permit the use of lipstick, powder and such lotions as are entirely free of fatty substances. We also allow brilliantine to be used on the hair but it must not be rubbed into the scalp. Obviously sun-tan oil is prohibited.
Many women are horrified when told that for the duration of treatment they cannot use face creams or have facial massages. They fear that this and the loss of weight will ruin their complexion. They can be fully reassured. Under treatment normal fat is restored to the skin, which rapidly becomes fresh and turgid, making the expression much more youthful. This is a characteristic of the HCG method which is a constant source of wonder to patients who have experienced or seen in others the facial ravages produced by the usual methods of reducing. An obese woman of 70 obviously cannot expect to have her pued face reduced to normal without a wrinkle, but it is remarkable how youthful her face remains in spite of her age.
Incidentally, another interesting feature of the HCG method is that it does not ruin a singing voice. The typically obese prima donna usually finds that when she tries to reduce, the timbre of her voice is liable to change, and understandably this terrifies her. Under HCG this does not happen; indeed, in many cases the voice improves and the breathing invariably does. We have had many cases of professional singers very carefully controlled by expert voice teachers, and the maestros have been so enthusiastic that they now frequently send us patients.