HCG Protocol

The Diet

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.


Breakfast:
Tea or coffee in any quantity without sugar. Only one tablespoonful of milk allowed in 24 hours. Saccharin or Stevia may be used.

Lunch:

1. 100 grams of veal, beef, chicken breast, fresh white fish, lobster, crab, or shrimp. All visible fat must be carefully removed before cooking, and the meat must be weighed raw. It must be boiled or grilled without additional fat. Salmon, eel, tuna, herring, dried or pickled fish are not allowed. The chicken breast must be removed from the bird.
2. One type of vegetable only to be chosen from the following: spinach, chard, chicory, beet-greens, green salad, tomatoes, celery, fennel, onions, red radishes, cucumbers, asparagus, cabbage.
3. One breadstick (grissino) or one Melba toast.
4. An apple, orange, or a handful of strawberries or one-half grapefruit.

Dinner :

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 he 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 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 never the less 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 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.

Making up the Calories

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 or shrimp, 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.
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.



Vegetarians

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.

Faulty Dieting

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 around 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, bide 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 self-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 clay, 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 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 Plateau

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. 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.

Menstrual Interruption

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.

Dietary Errors

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.

Water

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.

Constipation

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.


Cosmetics

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.

Other Reasons for a Gain

Apart from diet and cosmetics there can be a few other reasons for a small rise in weight. Some patients unwittingly take chewing gum, throat pastilles, vitamin pills, cough syrups etc., without realizing that the sugar or fats they contain may interfere with a regular loss of weight. Sex hormones or cortisone in its various modern forms must be avoided,
though oral contraceptives are permitted. In fact the only self-medication we allow is aspirin for a headache, though headaches almost invariably disappear after a week of treatment, particularly if of the migraine type.
Occasionally we allow a sleeping tablet or a tranquilizer, but patients should be told that while under treatment they need and may get less sleep. For instance, here in Italy where it is customary to sleep during the siesta which lasts from one to four in the afternoon most patients find that though they lie down they are unable to sleep.
We encourage swimming and sun bathing during treatment, but it should be remembered that a severe sunburn always produces a temporary rise in weight, evidently due to water retention. The same may be seen when a patient gets a common cold during treatment. Finally, the weight can temporarily increase - paradoxical though this may sound - after an exceptional physical exertion of long duration leading to a feeling of exhaustion. A game of tennis, a vigorous swim, a run, a ride on horseback or a round of golf do not have this effect; but a long trek, a day of skiing, rowing or cycling or dancing into the small hours usually result in a gain of weight on the following day, unless the patient is in perfect training. In patients coming from abroad, where they always use their cars, we often see this effect after a strenuous day of shopping on foot, sightseeing and visits to galleries and museums. Though the extra muscular effort involved does consume some additional calories, this appears to be offset by the retention of water which the tired circulation cannot at once eliminate.

Appetite-reducing Drugs

We hardly ever use amphetamines, the appetite-reducing drugs such as Dexedrin, Dexamil, Preludin, etc., as there seems to be no need for them during the hCG treatment. The only time we find them useful is when a patient is, for impelling and unforeseen reasons, obliged to forego the injections for three to four days and yet wishes to continue the diet so that he need not interrupt the course.

Unforeseen Interruptions of Treatment

If an interruption of treatment lasting more than four days is necessary, the patient must increase his diet to at least 800 calories by adding meat, eggs, cheese, and milk to his diet after the third day, as otherwise he will find himself so hungry and weak that he is unable to go about his usual occupation. If the interval lasts less than two weeks the patient can directly resume injections and the 500-calorie diet, but if the interruption lasts longer he must again eat normally until he has had his third injection.
When a patient knows beforehand that he will have to travel and be absent for more than four days, it is always better to stop injections three days before he is due to leave so that he can have the three days of strict dieting which are necessary after the last injection at home. This saves him from the almost impossible task of having to arrange the 500 calorie diet while en route, and he can thus enjoy a much greater dietary freedom from the day of his departure. Interruptions occurring before 20 effective injections have been given are most undesirable, because with less than that number of injections some weight is liable to be regained. After the 20th injection an unavoidable interruption is merely a loss of time.

Muscular Fatigue

Towards the end of a full course, when a good deal of fat has been rapidly lost, some patients complain that lifting a weight or climbing stairs requires a greater muscular effort than before. They feel neither breathlessness nor exhaustion but simply that their muscles have to work harder. This phenomenon, which disappears soon after the end of the treatment, is caused by the removal of abnormal fat deposited between, in, and around the muscles. The removal of this fat makes the muscles too long, and so in order to achieve a certain skeletal movement - say the bending of an arm - the muscles have to perform greater contraction than before. Within a short while the muscle adjusts itself perfectly to the new situation, but under hCG the loss of fat is so rapid that this adjustment cannot keep up with it. Patients often have to be reassured that this does not mean that they are ?getting weak?. This phenomenon does not occur in patients who regularly take vigorous exercise and continue to do so during treatment.

Massage

I never allow any kind of massage during treatment. It is entirely unnecessary and merely disturbs a very delicate process which is going on in the tissues. Few indeed are the masseurs and masseuses who can resist the temptation to knead and hammer abnormal fat deposits. In the course of rapid reduction it is sometimes possible to pick up a fold of skin which has not yet had time to adjust itself, as it always does under hCG, to the changed figure. This fold contains its normal subcutaneous fat and may be almost an inch thick. It is one of the main objects of the hCG treatment to keep that fat there. Patients and their masseurs do not always understand this and give this fat a working-over. I have seen such patients who were as black and blue as if they had received a sound thrashing.
In my opinion, massage, thumping, rolling, kneading, and shivering undertaken for the purpose of reducing abnormal fat can do nothing but harm. We once had the honor of treating the proprietress of a high class institution that specialized in such antics. She had the audacity to confess that she was taking our treatment to convince her clients of the efficacy of her methods, which she had found useless in her own case.
How anyone in his right mind is able to believe that fatty tissue can be shifted mechanically or be made to vanish by squeezing is beyond my comprehension. The only effect obtained is severe bruising. The torn tissue then forms scars, and these slowly contracts making the fatty tissue even harder and more unyielding.
A lady once consulted us for her most ungainly legs. Large masses of fat bulged over the ankles of her tiny feet, and there were about 40 lbs. too much on her hips and thighs. We assured her that this overweight could be lost and that her ankles would markedly improve in the process. Her treatment progressed most satisfactorily but to our surprise there was no improvement in her ankles. We then discovered that she had for years been taking every kind of mechanical, electric and heat treatment for her legs and that she had made up her mind to resort to plastic surgery if we failed.
Re-examining the fat above her ankles, we found that it was unusually hard. We attributed this to the countless minor injuries inflicted by kneading. These injuries had healed but had left a tough network of connective scar-tissue in which the fat was imprisoned. Ready to try anything, she was put to bed for the remaining three weeks of her first course with her lower legs tightly strapped in unyielding bandages. Every day the pressure was increased. The combination of hCG, diet and strapping brought about a marked improvement in the shape of her ankles. At the end of her first course she returned to her home abroad. Three months later she came back for her second course. She had maintained both her weight and the improvement of her ankles. The same procedure was repeated, and after five weeks she left the hospital with a normal weight and legs that, if not exactly shapely, were at least unobtrusive. Where no such injuries of the tissues have been inflicted by inappropriate methods of treatment, these drastic measures are never necessary.

Blood Sugar

Towards the end of a course or when a patient has nearly reached his normal weight it occasionally happens that the blood sugar drops below normal, and we have even seen this in patients who had an abnormally high blood sugar before treatment. Such an attack of hypoglycemia is almost identical with the one seen in diabetics who have taken too much insulin. The attack comes on suddenly; there is the same feeling of light-headedness, weakness in the knees, trembling, and unmotivated sweating. But under hCG, hypoglycemia does not produce any feeling of hunger. All these symptoms are almost instantly relieved by taking two heaped teaspoons of sugar.
In the course of treatment the possibility of such an attack is explained to those patients who are in a phase in which a drop in blood sugar may occur. They are instructed to keep sugar or glucose sweets handy, particularly when driving a car. They are also told to watch the effect of taking sugar very carefully and report the following day. This is important, because anxious patients to whom such an attack has been explained are apt to take sugar unnecessarily, in which case it inevitably produces a gain in weight and does not dramatically relieve the symptoms for which it was taken, proving that these were not due to hypoglycemia. Some patients mistake the effects of emotional stress for hypoglycemia. When the symptoms are quickly relieved by sugar this is proof that they were indeed due to an abnormal lowering of the blood sugar, and in that case there is no increase in the weight on the following day. We always suggest that sugar be taken if the patient is in doubt.
Once such an attack has been relieved with sugar we have never seen it recur on the immediately subsequent days, and only very rarely does a patient have two such attacks separated by several days during a course of treatment. In patients who have not eaten sufficiently during the first two days of treatment we sometimes give sugar when the minor symptoms usually felt during the first there days of treatment continue beyond that time, and in some cases this has seemed to speed up the euphoria ordinarily associated with the hCG method.

The Ratio of Pounds to Inches

An interesting feature of the hCG method is that, regardless of how fat a patient is, the greatest circumference -- abdomen or hips as the case may be is reduced at a constant rate which is extraordinarily close to 1 cm. per kilogram of weight lost. At the beginning of treatment the change in measurements is somewhat greater than this, but at the end of a course it is almost invariably found that the girth is as many centimeters less as the number of kilograms by which the weight has been reduced. I have never seen this clear cut relationship in patients that try to reduce by dieting only.