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Concluding a Course
When the three days of dieting after the last injection are over, the patients are told that they may now eat anything they please, except sugar and starch provided they faithfully observe one simple rule. This rule is that they must have their own portable bathroom-scale always at hand, particularly while traveling. They must without fail weight themselves every morning as they get out of bed, having first emptied their bladder. If they are in the habit of having breakfast in bed, they must weigh before breakfast.
It takes about 3 weeks before the weight reached at the end of the treatment becomes stable, i.e. does not show violent fluctuations after an occasional excess. During this period patients must realize that the so-called carbohydrates, that is sugar, rice, bread, potatoes, pastries etc, are by far the most dangerous. If no carbohydrates whatsoever are eaten, fats can be indulged in somewhat more liberally and even small quantities of alcohol, such as a glass of wine with meals, does no harm, but as soon as fats and starch are combined things are very liable to get out of hand. This has to be observed very carefully during the first 3 weeks after the treatment is ended otherwise disappointments are almost sure to occur.
Skipping a Meal
As long as their weight stays within two pounds of the weight reached on the day of the last injection, patients should take no notice of any increase but the moment the scale goes beyond two pounds, even if this is only a few ounces, they must on that same day entirely skip breakfast and lunch but take plenty to drink. In the evening they must eat a huge steak with only an apple or a raw tomato. Of course this rule applies only to the morning weight. Ex-obese patients should never check their weight during the day, as there may be wide fluctuations and these are merely alarming and confusing.
It is of utmost importance that the meal is skipped on the same day as the scale registers an increase of more than two pounds and that missing the meals is not postponed until the following day. If a meal is skipped on the day in which a gain is registered in the morning this brings about an immediate drop of often over a pound. But if the skipping of the meal - and skipping means literally skipping, not just having a light meal - is postponed the phenomenon does not occur and several days of strict dieting may be necessary to correct the situation.
Most patients hardly ever need to skip a meal. If they have eaten a heavy lunch they feel no desire to eat their dinner, and in this case no increase takes place. If they keep their weight at the point reached at the end of the treatment, even a heavy dinner does not bring about an increase of two pounds on the next morning and does not therefore call for any special measures. Most patients are surprised how small their appetite has become and yet how much they can eat without gaining weight. They no longer suffer from an abnormal appetite and feel satisfied with much less food than before. In fact, they are usually disappointed that they cannot manage their first normal meal, which they have been planning for weeks.
Losing More Weight
An ex-patient should never gain more than two pounds without immediately correcting this, but it is equally undesirable that more than two lbs. be lost after treatment, because a greater loss is always achieved at the expense of normal fat. Any normal fat that is lost is invariably regained as soon as more food is taken, and it often happens that this rebound overshoots the upper two lbs. limit.
Trouble After Treatment
Two difficulties may be encountered in the immediate post-treatment period. When a patient has consumed all his abnormal fat or, when after a full course, the injection has temporarily lost its efficacy owing to the body having gradually evolved a counter regulation, the patient at once begins to feel much more hungry and even weak. In spite of repeated warnings, some over-enthusiastic patients do not report this. However, in about two days the fact that they are being undernourished becomes visible in their faces, and treatment is then stopped at once. In such cases - and only in such cases - we allow a very slight increase in the diet, such as an extra apple, 150 grams of meat or two or three extra breadsticks during the three days of dieting after the last injection.
When abnormal fat is no longer being put into circulation either because it has been consumed or because immunity has set in, this is always felt by the patient as sudden, intolerable and constant hunger. In this sense, the hCG method is completely self-limiting. With hCG it is impossible to reduce a patient, however enthusiastic, beyond his normal weight. As soon as no more abnormal fat is being issued, the body starts consuming normal fat, and this is always regained as soon as ordinary feeding is resumed. The patient then finds that the 2-3 lbs. he has lost during the last days of treatment are immediately regained. A meal is skipped and maybe a pound is lost. The next day this pound is regained, in spite of a careful watch over the food intake. In a few days a tearful patient is back in the consulting room, convinced that her case is a failure.
All that is happening is that the essential fat lost at the end of the treatment, owing to the patient's reluctance to report a much greater hunger, is being replaced. The weight at which such a patient must stabilize thus lies 2-3 lbs. higher than the weight reached at the end of the treatment. Once this higher basic level is established, further difficulties in controlling the weight at the new point of stabilization hardly arise.
Beware of Over-Enthusiasm
The other trouble which is frequently encountered immediately after treatment is again due to over-enthusiasm. Some patients cannot believe that they can eat fairly normally without regaining weight. They disregard the advice to eat anything they please except sugar and starch and want to play safe. They try more or less to continue the 500-calorie diet on which they felt so well during treatment and make only minor variations, such as replacing the meat with an egg, cheese, or a glass of milk. To their horror they find that in spite of this bravura, their weight goes up. So, following instructions, they skip one meager lunch and at night eat only a little salad and drink a pot of unsweetened tea, becoming increasingly hungry and weak. The next morning they find that they have increased yet another pound. They feel terrible, and even the dreaded swelling of their ankles is back. Normally we check our patients one week after they have been eating freely, but these cases return in a few days. Either their eyes are filled with tears or they angrily imply that when we told them to eat normally we were just fooling them.
Here too, the explanation is quite simple. During treatment the patient has been only just above the verge of protein deficiency and has had the advantage of protein being fed back into his system from the breakdown of fatty tissue. Once the treatment is over there is no more hCG in the body and this process no longer takes place. Unless an adequate amount of protein is eaten as soon as the treatment is over, protein deficiency is bound to develop, and this inevitably causes the marked retention of water known as hunger- edema.
The treatment is very simple. The patient is told to eat two eggs for breakfast and a huge steak for lunch and dinner followed by a large helping of cheese and to phone through the weight the next morning. When these instructions are followed a stunned voice is heard to report that two lbs. have vanished overnight, that the ankles are normal but that sleep was disturbed, owing to an extraordinary need to pass large quantities of water. The patient having learned this lesson usually has no further trouble.
As a general rule one can say that 60%-70% of our cases experience little or no difficulty in holding their weight permanently. Relapses may be due to negligence in the basic rule of daily weighing. Many patients think that this is unnecessary and that they can judge any increase from the fit of their clothes. Some do not carry their scale with them on a journey as it is cumbersome and takes a big bite out of their luggage-allowance when flying. This is a disastrous mistake, because after a course of hCG as much as 10 lbs. can be regained without any noticeable change in the fit of the clothes. The reason for this is that after treatment newly acquired fat is at first evenly distributed and does not show the former preference for certain parts of the body.
Pregnancy or the menopause may annul the effect of a previous treatment. Women who take treatment during the one year after the last menstruation - that is at the onset of the menopause - do just as well as others, but among them the relapse rate is higher until the menopause is fully established. The period of one year after the last menstruation applies only to women who are not being treated with ovarian hormones. If these are taken, the premenopausal period may be indefinitely prolonged.
Late teenage girls who suffer from attacks of compulsive eating have by far the worst record of all as far as relapses are concerned.
Patients who have once taken the treatment never seem to hesitate to come back for another short course as soon as they notice that their weight is once again getting out of hand. They come quite cheerfully and hopefully, assured that they can be helped again. Repeat courses are often even more satisfactory than the first treatment and have the advantage, as do second courses, that the patient already, knows that he will feel comfortable throughout.
Plan of a Normal Course
125 I.U. of hCG daily (except during menstruation) ui injections have been given.
Until 3rd injection forced feeding.
After 3rd injection, 500 calorie diet to be continued until 72 hours after the last injection.
For the following 3 weeks, all foods allowed except starch and sugar in any form (careful with very sweet fruit).
After 3 weeks, very gradually add starch in small quantities, always controlled by morning weighing.
The hCG + diet method can bring relief to every case of obesity, but the method is not simple. It is very time consuming and requires perfect cooperation between physician and patient. Each case must be handled individually, and the physician must have time to answer questions, allay fears and remove misunderstandings. He must also check the patient daily. When something goes wrong he must at once investigate until he finds the reason for any gain that may have occurred. In most cases it is useless to hand the patient a diet-sheet and let the nurse give him a "shot."
The method involves a highly complex bodily mechanism, and the physician must make himself some sort of picture of what is actually happening; otherwise he will not be able to deal with such difficulties as may arise during treatment.
I must beg those trying the method for the first time to adhere very strictly to the technique and the interpretations here outlined and thus treat a few hundred cases before embarking on experiments of their own, and until then refrain from introducing innovations, however thrilling they may seem. In a new method, innovations or departures from the original technique can only be usefully evaluated against a substantial background of experience with what is at the moment the orthodox procedure.
I have tried to cover all the problems that come to my mind. Yet a bewildering array of new questions keeps arising, and my interpretations are still fluid. In particular, I have never had an opportunity of conducting the laboratory investigations which are so necessary for a theoretical understanding of clinical observations, and I can only hope that those more fortunately placed will in time be able to fill this gap.
The problems of obesity are perhaps not so dramatic as the problems of cancer, but they often cause life long suffering. How many promising careers have been ruined by excessive fat; how many lives have been shortened. If some way -however cumbersome - can be found to cope effectively with this universal problem of modern civilized man, our world will be a happier place for countless fellow men and women.
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