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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 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.
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.