Some complicating disorders are often associated with obesity, and these we must briefly discuss. The most important associated disorders and the ones in which obesity seems to play a precipitating or at least an aggravating role are the following: the stable type of diabetes, gout, rheumatism and arthritis, high blood pressure and hardening of the arteries, coronary disease and cerebral hemorrhage.
Apart from the fact that they are often - though not necessarily - associated with obesity, these disorders have two things in common. In all of them, modern research is becoming more and more inclined to believe that diencephalic regulations play a dominant role in their causation. The other common factor is that they either improve or do not occur during pregnancy. In the latter respect they are joined by many other disorders not necessarily associated with obesity. Such disorders are, for instance, colitis, duodenal or gastric ulcers, certain allergies, psoriasis, loss of hair, brittle fingernails, migraine, etc.
If HCG + diet does in the obese bring about those diencephalic changes which are characteristic of pregnancy, one would expect to see an improvement in all these conditions comparable to that seen in real pregnancy. The administration of HCG does in fact do this in a remarkable way.
In an obese patient suffering from a fairly advanced case of stable diabetes of many years duration in which the blood sugar may range from 3-400 mg%, it is often possible to stop all antidiabetic medication after the first few days of treatment. The blood sugar continues to drop from day to day and often reaches normal values in 2-3 weeks. As in pregnancy, this phenomenon is not observed in the brittle type of diabetes, and as some cases that are predominantly stable may have a small brittle factor in their clinical makeup, all obese diabetics have to be kept under a very careful and expert watch.
A brittle case of diabetes is primarily due to the inability of the pancreas to produce sufficient insulin, while in the stable type, diencephalic regulations seem to be of greater importance. That is possibly the reason why the stable form responds so well to the HCG method of treating obesity, whereas the brittle type does not. Obese patients are generally suffering from the stable type, but a stable type may gradually change into a brittle one, which is usually associated with a loss of weight. Thus, when an obese diabetic finds that he is losing weight without diet or treatment, he should at once have his diabetes expertly attended to. There is some evidence to suggest that the change from stable to brittle is more liable to occur in patients who are taking insulin for their stable diabetes.
All rheumatic pains, even those associated with demonstrable bony lesions, improve subjectively within a few days of treatment, and often require neither cortisone nor salicylates. Again this is a well known phenomenon in pregnancy, and while under treatment with HCG + diet the effect is no less dramatic. As it does after pregnancy, the pain of deformed joints returns after treatment, but smaller doses of pain-relieving drugs seem able to control it satisfactorily after weight reduction. In any case, the HCG method makes it possible in obese arthritic patients to interrupt prolonged cortisone treatment without a recurrence of pain. This in itself is most welcome, but there is the added advantage that the treatment stimulates the secretion of ACTH in a physiological manner and that this regenerates the adrenal cortex, which is apt to suffer under prolonged cortisone treatment.
The exact extent to which the blood cholesterol is involved in hardening of the arteries, high blood pressure and coronary disease is not as yet known, but it is now widely admitted that the blood cholesterol level is governed by diencephalic mechanisms. The behavior of circulating cholesterol is therefore of particular interest during the treatment of obesity with HCG. Cholesterol circulates in two forms, which we call free and esterified. Normally these fractions are present in a proportion of about 25% free to 75% esterified cholesterol, and it is the latter fraction which damages the walls of the arteries. In pregnancy this proportion is reversed and it may he taken for granted that arteriosclerosis never gets worse during pregnancy for this very reason.
To my knowledge, the only other condition in which the proportion of free to esterified cholesterol is reversed is during the treatment of obesity with HCG + diet, when exactly the same phenomenon takes place. This seems an important indication of how closely a patient under HCG treatment resembles a pregnant woman in diencephalic behavior.
When the total amount of circulating cholesterol is normal before treatment, this absolute amount is neither significantly increased nor decreased. But when an obese patient with an abnormally high cholesterol and already showing signs of arteriosclerosis is treated with HCG, his blood pressure drops and his coronary circulation seems to improve, and yet his total blood cholesterol may soar to heights never before reached.
At first this greatly alarmed us. But then we saw that the patients came to no harm even if treatment was continued and we found in follow-up examinations undertaken some months after treatment that the cholesterol was much better than it had been before treatment. As the increase is mostly in the form of the not dangerous free cholesterol, we gradually came to welcome the phenomenon. Today we believe that the rise is entirely due to the liberation of recent cholesterol deposits that have not yet undergone calcification in the arterial wall and therefore highly beneficial.
An identical behavior is found in the blood uric acid level of patients suffering from gout. Predictably such patients get an acute and often severe attack after the first few days of HCG treatment but then remain entirely free of pain, in spite of the fact that their blood uric acid often shows a marked increase which may persist for several months after treatment. Those patients who have regained their normal weight remain free of symptoms regardless of what they eat, while those that require a second course of treatment get another attack of gout as soon as the second course is initiated. We do not yet know what diencephalic mechanisms are involved in gout; possibly emotional factors play a role, and it is worth remembering that the disease does not occur in women of childbearing age. We now give 2 tablets daily of ZYLORIC to all patients who give a history of gout and have a high blood uric acid level. In this way we can completely avoid attacks during treatment.
Patients who have brought themselves to the brink of malnutrition by exaggerated dieting, laxatives etc, often have an abnormally low blood pressure. In these cases the blood pressure rises to normal values at the beginning of treatment and then very gradually drops, as it always does in patients with a normal blood pressure. Normal values are always regained a few days after the treatment is over. Of this lowering of the blood pressure during treatment the patients are not aware. When the blood pressure is abnormally high, and provided there are no detectable renal lesions, the pressure drops, as it usually does in pregnancy. The drop is often very rapid, so rapid in fact that it sometimes is advisable to slow down the process with pressure-sustaining medication until the circulation has had a few days time to adjust itself to the new situation. On the other hand, among the thousands of cases treated we have never seen any untoward incident which could be attributed to the rather sudden drop in high blood pressure.
When a woman suffering from high blood pressure becomes pregnant her blood pressure very soon drops, but after her confinement it may gradually rise back to its former level. Similarly, a high blood pressure present before HCG treatment tends to rise again after the treatment is over, though this is not always the case. But the former high levels are rarely reached, and we have gathered the impression that such relapses respond better to orthodox drugs such as Reserpine than before treatment.
In our cases of obesity with gastric or duodenal ulcers we have noticed a surprising subjective improvement in spite of a diet which would generally be considered most inappropriate for an ulcer patient. Here, too, there is a similarity with pregnancy, in which peptic ulcers hardly ever occur. However we have seen two cases with a previous history of several hemorrhages in which a bleeding occurred within 2 weeks of the end of treatment.
As in pregnancy, psoriasis greatly improves during treatment but may relapse when the treatment is over. Most patients spontaneously report a marked improvement in the condition of brittle fingernails. The loss of hair not infrequently associated with obesity is temporarily arrested, though in very rare cases an increased loss of hair has been reported. I remember a case in which a patient developed a patchy baldness - so-called alopecia areata - after a severe emotional shock, just before she was about to start an HCG treatment. Our dermatologist diagnosed the case as a particularly severe one, predicting that all the hair would be lost. He counseled against the reducing treatment, but in view of my previous experience and as the patient was very anxious not to postpone reducing, I discussed the matter with the dermatologist and it was agreed that, having fully acquainted the patient with the situation, the treatment should be started. During the treatment, which lasted four weeks, the further development of the bald patches was almost, if not quite, arrested; however, within a week of having finished the course of HCG, all the remaining hair fell out as predicted by the dermatologist. The interesting point is that the treatment was able to postpone this result but not to prevent it. The patient has now grown a new shock of hair of which she is justly proud.
In obese patients with large varicose ulcers we were surprised to find that these ulcers heal rapidly under treatment with HCG. We have since treated non obese patients suffering from varicose ulcers with daily injections of HCG on normal diet with equally good results.
When a male patient hears that he is about to be put into a condition which in some respects resembles pregnancy, he is usually shocked and horrified. The physician must therefore carefully explain that this does not mean that he will be feminized and that HCG in no way interferes with his sex. He must be made to understand that in the interest of the propagation of the species nature provides for a perfect functioning of the regulatory headquarters in the diencephalon during pregnancy and that we are merely using this natural safeguard as a means of correcting the diencephalic disorder which is responsible for his overweight.
I must warn the lay reader that what follows is mainly for the treating physician and most certainly not a do-it-yourself primer. Many of the expressions used mean something entirely different to a qualified doctor than that which their common use implies, and only a physician can correctly interpret the symptoms which may arise during treatment. Any patient who thinks he can reduce by taking a few "shots" and eating less is not only sure to be disappointed but may be heading for serious trouble. The benefit the patient can derive from reading this part of the book is a fuller realization of how very important it is for him to follow to the letter his physician's instructions.
In treating obesity with the HCG + diet method we are handling what is perhaps the most complex organ in the human body. The diencephalon's functional equilibrium is delicately poised, so that whatever happens in one part has repercussions in others. In obesity this balance is out of kilter and can only be restored if the technique I am about to describe is followed implicitly. Even seemingly insignificant deviations, particularly those that at first sight seem to be an improvement, are very liable to produce most disappointing results and even annul the effect completely. For instance, if the diet is increased from 500 to 600 or 700 Calories, the loss of weight is quite unsatisfactory. If the daily dose of HCG is raised to 200 or more units daily its action often appears to be reversed, possibly because larger doses evoke diencephalic counter-regulations. On the other hand, the diencephalon is an extremely robust organ in spite of its unbelievable intricacy. From an evolutionary point of view it is one of the oldest organs in our body and its evolutionary history dates back more than 500 million years. This has tendered it extraordinarily adaptable to all natural exigencies, and that is one of the main reasons why the human species was able to evolve. What its evolution did not prepare it for were the conditions to which human culture and civilization now expose it.
When a patient first presents himself for treatment, we take a general history and note the time when the first signs of overweight were observed. We try to establish the highest weight the patient has ever had in his life (obviously excluding pregnancy), when this was, and what measures have hitherto been taken in an effort to reduce.
It has been our experience that those patients who have been taking thyroid preparations for long periods have a slightly lower average loss of weight under treatment with HCG than those who have never taken thyroid. This is even so in those patients who have been taking thyroid because they had an abnormally low basal metabolic rate. In many of these cases the low BMR is not due to any intrinsic deficiency of the thyroid gland, but rather to a lack of diencephalic stimulation of the thyroid gland via the anterior pituitary lobe. We never allow thyroid to be taken during treatment, and yet a BMR which was very low before treatment is usually found to be normal after a week or two of HCG + diet. Needless to say, this does not apply to those cases in which a thyroid deficiency has been produced by the surgical removal of a part of an overactive gland. It is also most important to ascertain whether the patient has taken diuretics (water eliminating pills) as this also decreases the weight loss under the HCG regimen.
Returning to our procedure, we next ask the patient a few questions to which he is held to reply simply with "yes" or "no". These questions are: Do you suffer from headaches? rheumatic pains? menstrual disorders? constipation? breathlessness or exertion? swollen ankles? Do you consider yourself greedy? Do you feel the need to eat snacks between meals?
The patient then strips and is weighed and measured. The normal weight for his height, age, skeletal and muscular build is established from tables of statistical averages, whereby in women it is often necessary to make an allowance for particularly large and heavy breasts. The degree of overweight is then calculated, and from this the duration of treatment can be roughly assessed on the basis of an average loss of weight of a little less than a pound, say 300-400 grams-per injection, per day. It is a particularly interesting feature of the HCG treatment that in reasonably cooperative patients this figure is remarkably constant, regardless of sex, age and degree of overweight.
Patients who need to lose 15 pounds (7 kg.) or less require 26 days treatment with 23 daily injections. The extra three days are needed because all patients must continue the 500-Calorie diet for three days after the last injection. This is a very essential part of the treatment, because if they start eating normally as long as there is even a trace of HCG in their body they put on weight alarmingly at the end of the treatment. After three days when all the HCG has been eliminated this does not happen, because the blood is then no longer saturated with food and can thus accommodate an extra influx from the intestines without increasing its volume by retaining water.
We never give a treatment lasting less than 26 days, even in patients needing to lose only 5 pounds. It seems that even in the mildest cases of obesity the diencephalon requires about three weeks rest from the maximal exertion to which it has been previously subjected in order to regain fully its normal fat-banking capacity. Clinically this expresses itself in the fact that when in these mild cases treatment is stopped as soon as the weight is normal, which may be achieved in a week, it is much more easily regained than after a full course of 23 injections.
As soon as such patients have lost all their abnormal superfluous fat, they at once begin to feel ravenously hungry in spite of continued injections. This is because HCG only puts abnormal fat into circulation and cannot, in the doses used, liberate normal fat deposits; indeed, it seems to prevent their consumption. As soon as their statistically normal weight is reached, these patients are put on 800-1000 Calories for the rest of the treatment. The diet is arranged in such a way that the weight remains perfectly stationary and is thus continued for three days after the 23rd injection. Only then are the patients free to eat anything they please except sugar and starches for the next three weeks.
Such early cases are common among actresses, models, and persons who are tired of obesity, having seen its ravages in other members of their family. Film actresses frequently explain that they must weigh less than normal. With this request we flatly refuse to comply, first, because we undertake to cure a disorder, not to create a new one, and second, because it is in the nature of the HCG method that it is self limiting. It becomes completely ineffective as soon as all abnormal fat is consumed. Actresses with a slight tendency to obesity, having tried all manner of reducing methods, invariably come to the conclusion that their figure is satisfactory only when they are underweight, simply because none of these methods remove their superfluous fat deposits. When they see that under HCG their figure improves out of all proportion to the amount of weight lost, they are nearly always content to remain within their normal weight-range.
When a patient has more than 15 pounds to lose the treatment takes longer but the maximum we give in a single course is 40 injections, nor do we as a rule allow patients to lose more than 34 lbs. (15 Kg.) at a time. The treatment is stopped when either 34 lbs. have been lost or 40 injections have been given. The only exception we make is in the case of grotesquely obese patients who may be allowed to lose an additional 5-6 lbs. if this occurs before the 40 injections are up.
The reason for limiting a course to 40 injections is that by then some patients may begin to show signs of HCG immunity. Though this phenomenon is well known, we cannot as yet define the underlying mechanism. Maybe after a certain length of time the body learns to break down and eliminate HCG very rapidly, or possibly prolonged treatment leads to some sort of counter-regulation which annuls the diencephalic effect.
After 40 daily injections it takes about six weeks before this so-called immunity is lost and HCG again becomes fully effective. Usually after about 40 injections patients may feel the onset of immunity as hunger which was previously absent. In those comparatively rare cases in which signs of immunity develop before the full course of 40 injections has been completed - say at the 35th injection - treatment must be stopped at once, because if it is continued the patients begin to look weary and drawn, feel weak and hungry and any further loss of weight achieved is then always at the expense of normal fat. This is not only undesirable, but normal fat is also instantly regained as soon as the patient is returned to a free diet.
Patients who need only 23 injections may be injected daily, including Sundays, as they never develop immunity. In those that take 40 injections the onset of immunity can be delayed if they are given only six injections a week, leaving out Sundays or any other day they choose, provided that it is always the same day. On the days on which they do not receive the injections they usually feel a slight sensation of hunger. At first we thought that this might be purely psychological, but we found that when normal saline is injected without the patient's knowledge the same phenomenon occurs.
During menstruation no injections are given, but the diet is continued and causes no hardship; yet as soon as the menstruation is over, the patients become extremely hungry unless the injections are resumed at once. It is very impressive to see the suffering of a woman who has continued her diet for a day or two beyond the end of the period without coming for her injection and then to hear the next day that all hunger ceased within a few hours after the injection and to see her once again content, florid and cheerful. While on the question of menstruation it must he added that in teenaged girls the period may in some rare cases be delayed and exceptionally stop altogether. If then later this is artificially induced some weight may be regained.
Patients requiring the loss of more than 34 lbs. must have a second or even more courses. A second course can be started after an interval of not less than six weeks, though the pause can be more than six weeks. When a third, fourth or even fifth course is necessary, the interval between courses should be made progressively longer. Between a second and third course eight weeks should elapse, between a third and fourth course twelve weeks, between a fourth and fifth course twenty weeks and between a fifth and sixth course six months. In this way it is possible to bring about a weight reduction of 100 lbs. and more if required without the least hardship to the patient.
In general, men do slightly better than women and often reach a somewhat higher average daily loss. Very advanced cases do a little better than early ones, but it is a remarkable fact that this difference is only just statistically significant.
On the basis of these data the probable duration of treatment can he calculated with considerable accuracy, and this is explained to the patient. It is made clear to him that during the course of treatment he must attend the clinic daily to be weighed, injected and generally checked. All patients that live in Rome or have resident friends or relations with whom they can stay are treated as out-patients, but patients coming from abroad must stay in the hospital, as no hotel or restaurant can be relied upon to prepare the diet with sufficient accuracy. These patients have their meals, sleep, and attend the clinic in the hospital, but are otherwise free to spend their time as they please in the city and its surroundings sightseeing, bathing or theater-going.
It is also made clear that between courses the patient gets no treatment and is free to eat anything he pleases except starches and sugar during the first 3 weeks. It is impressed upon him that he will have to follow the prescribed diet to the letter and that after the first three days this will cost him no effort, as he will feel no hunger and may indeed have difficulty in getting down the 500 Calories which he will be given. If these conditions are not acceptable the case is refused, as any compromise or half-measure is bound to prove utterly disappointing to patient and physician alike and is a waste of time and energy.
Though a patient can only consider himself really cured when he has been reduced to his stastically normal weight, we do not insist that he commit himself to that extent. Even a partial loss of overweight is highly beneficial, and it is our experience that once a patient has completed a first course he is so enthusiastic about the ease with which the - to him surprising - results are achieved that he almost invariably comes back for more. There certainly can be no doubt that in my clinic more time is spent on damping over-enthusiasm than on insisting that the rules of the treatment be observed.
Only when agreement is reached on the points so far discussed do we proceed with the examination of the patient. A note is made of the size of the first upper incisor, of a pad of fat on the nape of the neck, at the axilla and on the inside of the knees. The presence of striation, a suprapubic fold, a thoracic fold, angulation of elbow and knee joint, breast-development in men and women, edema of the ankles and the state of genital development in the male are noted.
Wherever this seems indicated we X-ray the sella turcica, as the bony capsule which contains the pituitary gland is called, measure the basal metabolic rate, X-ray the chest and take an electrocardiogram. We do a blood-count and a sedimentation rate and estimate uric acid, cholesterol, iodine and sugar in the fasting blood.
Patients whose general condition is low, owing to excessive previous dieting, must eat to capacity for about one week before starting treatment, regardless of how much weight they may gain in the process. One cannot keep a patient comfortably on 500 Calories unless his normal fat reserves are reasonably well stocked. It is for this reason also that every case, even those that are actually gaining must eat to capacity of the most fattening food they can get down until they have had the third injection. It is a fundamental mistake to put a patient on 500 Calories as soon as the injections are started, as it seems to take about three injections before abnormally deposited fat begins to circulate and thus become available.
We distinguish between the first three injections, which we call "non-effective" as far as the loss of weight is concerned, and the subsequent injections given while the patient is dieting, which we call "effective". The average loss of weight is calculated on the number of effective injections and from the weight reached on the day of the third injection, which may be well above what it was two days earlier when the first injection was given.
Most patients who have been struggling with diets for years and know how rapidly they gain if they let themselves go are very hard to convince of the absolute necessity of gorging for at least two days, and yet this must he insisted upon categorically if the further course of treatment is to run smoothly. Those patients who have to be put on forced feeding for a week before starting the injections usually gain weight rapidly - four to six pounds in 24 hours is not unusual - but after a day or two this rapid gain generally levels off. In any case, the whole gain is usually lost in the first 48 hours of dieting. It is necessary to proceed in this manner because the gain re-stocks the depleted normal reserves, whereas the subsequent loss is from the abnormal deposits only.
Patients in a satisfactory general condition and those who have not just previously restricted their diet start forced feeding on the day of the first injection. Some patents say that they can no longer overeat because their "stomach has shrunk" after years of restrictions. While we know that no stomach ever shrinks, we compromise by insisting that they eat frequently of highly concentrated foods such as milk chocolate, pastries with whipped cream, sugar, fried meats (particularly pork), eggs and bacon, mayonnaise, bread with thick butter and jam, etc. The time and trouble spent on pressing this point upon incredulous or reluctant patients is always amply rewarded afterwards by the complete absence of those difficulties which patients who have disregarded these instructions are liable to experience.
During the two days of forced feeding from the first to the third injection - many patients are surprised that contrary to their previous experience they do not gain weight and some even lose. The explanation is that in these cases there is a compensatory flow of urine, which drains excessive water from the body. To some extent this seems to be a direct action of HCG, but it may also be due to a higher protein intake, as we know that a protein-deficient diet makes the body retain water.
In menstruating women, the best time to start treatment is immediately after a period. Treatment may also be started later, but it is advisable to have at least ten days in hand before the onset of the next period. Similarly, the end of a course of HCG should never be made to coincide with menstruation. If things should happen to work out that way, it is better to give the last injection three days before the expected date of the menses so that a normal diet can he resumed at onset. Alternatively, at least three injections should be given after the period, followed by the usual three days of dieting. This rule need not be observed in such patients who have reached their normal weight before the end of treatment and are already on a higher caloric diet.
Patients who require more than the minimum of 23 injections and who therefore skip one day a week in order to postpone immunity to HCG cannot have their third injections on the day before the interval. Thus if it is decided to skip Sundays, the treatment can be started on any day of the week except Thursdays. Supposing they start on Thursday, they will have their third injection on Saturday, which is also the day on which they start their 500 Calorie diet. They would then have no injection on the second day of dieting; this exposes them to an unnecessary hardship, as without the injection they will feel particularly hungry. Of course, the difficulty can be overcome by exceptionally injecting them on the first Sunday. If this day falls between the first and second or between the second and third injection, we usually prefer to give the patient the extra day of forced feeding, which the majority rapturously enjoy.
The 500 Calorie diet is explained on the day of the second injection to those patients who will be preparing their own food, and it is most important that the person who will actually cook is present - the wife, the mother or the cook, as the case may be. Here in Italy patients are given the following diet sheet.
Tea or coffee in any quantity without sugar. Only one tablespoonful of milk allowed in 24 hours. Saccharin or other sweeteners may be used.
The same four choices as lunch.
The juice of one lemon daily is allowed for all purposes. Salt, pepper, vinegar, mustard powder, garlic, sweet basil, parsley, thyme, majoram, etc., may be used for seasoning, but no oil, butter or dressing.
Tea, coffee, plain water, or mineral water are the only drinks allowed, but they may be taken in any quantity and at all times.
In fact, the patient should drink about 2 liters of these fluids per day. Many patients are afraid to drink so much because they fear that this may make them retain more water. This is a wrong notion as the body is more inclined to store water when the intake falls below its normal requirements.
The fruit or the breadstick may be eaten between meals instead of with lunch or dinner, but not more than than four items listed for lunch and dinner may be eaten at one meal.
No medicines or cosmetics other than lipstick, eyebrow pencil and powder may be used without special permission
Every item in the list is gone over carefully, continually stressing the point that no variations other than those listed may be introduced. All things not listed are forbidden, and the patient is assured that nothing permissible has been left out. The 100 grams of meat must he scrupulously weighed raw after all visible fat has been removed. To do this accurately the patient must have a letter-scale, as kitchen scales are not sufficiently accurate and the butcher should certainly not be relied upon. Those not uncommon patients who feel that even so little food is too much for them, can omit anything they wish.
There is no objection to breaking up the two meals. For instance having a breadstick and an apple for breakfast or an orange before going to bed, provided they are deducted from the regular meals. The whole daily ration of two breadsticks or two fruits may not be eaten at the same time, nor can any item saved from the previous day be added on the following day. In the beginning patients are advised to check every meal against their diet sheet before starting to eat and not to rely on their memory. It is also worth pointing out that any attempt to observe this diet without HCG will lead to trouble in two to three days. We have had cases in which patients have proudly flaunted their dieting powers in front of their friends without mentioning the fact that they are also receiving treatment with HCG. They let their friends try the same diet, and when this proves to be a failure - as it necessarily must - the patient starts raking in unmerited kudos for superhuman willpower.
It should also be mentioned that two small apples weighing as much as one large one nevertheless have a higher caloric value and are therefore not allowed, though there is no restriction on the size of one apple. Some people do not realize that a tangerine is not an orange and that chicken breast does not mean the breast of any other fowl, nor does it mean a wing or drumstick.
The most tiresome patients are those who start counting Calories and then come up with all manner of ingenious variations which they compile from their little books. When one has spent years of weary research trying to make a diet as attractive as possible without jeopardizing the loss of weight, culinary geniuses who are out to improve their unhappy lot are hard to take.
The diet used in conjunction with HCG must not exceed 500 Calories per day, and the way these Calories are made up is of utmost importance. For instance, if a patient drops the apple and eats an extra breadstick instead, he will not be getting more Calories but he will not lose weight. There are a number of foods, particularly fruits and vegetables, which have the same or even lower caloric values than those listed as permissible, and yet we find that they interfere with the regular loss of weight under HCG, presumably owing to the nature of their composition. Pimiento peppers, okra, artichokes and pears are examples of this.
While this diet works satisfactorily in Italy, certain modifications have to be made in other countries. For instance, American beef has almost double the caloric value of South Italian beef, which is not marbled with fat. This marbling is impossible to remove. In America, therefore, low-grade veal should be used for one meal and fish (excluding all those species such as herring, mackerel, tuna, salmon, eel, etc., which have a high fat content, and all dried, smoked or pickled fish), chicken breast, lobster, crawfish, prawns, shrimps, crabmeat or kidneys for the other meal. Where the Italian breadsticks, the so-called grissini, are not available, one Melba toast may be used instead, though they are psychologically less satisfying. A Melba toast has about the same weight as the very porous grissini which is much more to look at and to chew.
In many countries specially prepared unsweetened and low Calorie foods are freely available, and some of these can be tentatively used. When local conditions or the feeding habits of the population make changes necessary, it must be borne in mind that the total daily intake must not exceed 500 Calories if the best possible results are to be obtained, that the daily ration should contain 200 grams of fat-free protein and a very small amount of starch.
Just as the daily dose of HCG is the same in all cases, so the same diet proves to be satisfactory for a small elderly lady of leisure or a hard working muscular giant. Under the effect of HCG the obese body is always able to obtain all the Calories it needs from the abnormal fat deposits, regardless of whether it uses up 1500 or 4000 per day. It must be made very clear to the patient that he is living to a far greater extent on the fat which he is losing than on what he eats.
Many patients ask why eggs are not allowed. The contents of two good sized eggs are roughly equivalent to 100 grams of meat, but fortunately the yolk contains a large amount of fat, which is undesirable. Very occasionally we allow egg - boiled, poached or raw - to patients who develop an aversion to meat, but in this case they must add the white of three eggs to the one they eat whole. In countries where cottage cheese made from skimmed milk is available 100 grams may occasionally be used instead of the meat, but no other cheeses are allowed.
Strict vegetarians such as orthodox Hindus present a special problem, because milk and curds are the only animal protein they will eat. To supply them with sufficient protein of animal origin they must drink 500 cc. of skimmed milk per day, though part of this ration can be taken as curds. As far as fruit, vegetables and starch are concerned, their diet is the same as that of non-vegetarians; they cannot be allowed their usual intake of vegetable proteins from leguminous plants such as beans or from wheat or nuts, nor can they have their customary rice. In spite of these severe restrictions, their average loss is about half that of non-vegetarians, presumably owing to the sugar content of the milk.
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.
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.