Qi Gong Graphic Weight Issues:
Body Image & Eating Disorders in Women

by Mary Kay Ryan
and Maureen McLaughlin


From Oriental Medicine Journal Volume 5, #2
It is very common in our experience for women patients to contact practitioners of Chinese medicine for weightloss. Even more often, issues of weight and weight loss arise during treatment of toher health issues. ("Is it true that acupuncture can help you lose weight?") Weight and body image play a very large role in the self esteem of women in this country. This is true because north American culture places such a heavy emphasis on conformity to certain body norms, many of them extremely unhealthy for women. Practitioners of oriental medicine are often not fully aware of or trained in the complex psychosocial issues that come into play while treating patients for "weight loss."

In this article we will present three very different cases in which weight, body image and so on played a significant role, using them to raise some of these issues and compare and contrast the ways in which they might arise. We will also attempt to show where Chinese medicine will be most successful and where the psychological makeup of the patient will assist or interfere with success.

Case #1

Patient was a 38-year-old woman presenting with complaints of swollen, painful, edematous joints, numbness developing in the upper limbs, sinus congestion, headache, nausea and indigestion, water retention and weight gain. (She was 5' tall and weighed 318 lbs.) The patient did not list weight loss as a primary concern, nor raise it very slgnificantly in the initial interview. She was interested in treating her joint pain, sinus problems, and gastrointestinal disturbances. Pulse was very deep, soft and slippery. Tongue was pale with a white glossy, sometimes sticky coat.

Syndrome Differentiation

This was a case of severe accumulation of tan (phlegm damp) and water collecting contributing to wind damp bi. This systemic damp stagnation was also causing some mild heat rising. More significant, however, was her way of conceiving of her health concerns. She did not seem to see them in the context of her weight and wanted to treat the sinuses, joints, and so on "first." She was reluctant to discuss her weight at all, reported that she had "tried to lose weight before, but gained it all back." She had great difficulty reporting her eating habits, regularly reported having "No appetite" or "ordinary appetite," clearly an impossibility. In short she acted as if she was oblivious of her weight (which she could not have been since she had difficuIty even walking without becoming winded.) This is one common way in which an eating disordered patient can present. She was disconnected from her very extreme weight problem, probably deeply embarrassed by it and separated and ashamed of her body in general. She was unable to engage in any realistic discussion of it. She was, in short, in severe denial.

Treatment Principle

Expel phlegm damp systemically and in the joints, tonify the Kidneys and Spleen to dispel damp. Clear and anchor rising heat. Included in this TCM strategy, however, must be some sense of how to approach the larger psychological issues and connect the patient to the reality of her problem. The practitioner herself must be aware of the seriousness of the problem and avoid assisting in the denial--sometimes difficult to do.

Discussion of Treatment

Acupuncture: Treated once a week.
Herbs: Si Ling San, Xiao Ying Long Dan + yi yi ren (coix seed) + Fat Reducing Tea.
We also recommended qi gong class to the patient.

Results

The sinus and gastrointestinal problems were sirmificantly better within one month. The joint pain was better within two months. Patient did take qi gong class and enjoyed it. Practiced for about a month. Patient did not comply well with herb regimen. She seemed unable to ingest anything that might affect her health in a positive way. At the end of one month, she stopped all herbs, did an about face and went on a drug regimen with a physician for weight loss. Reported losing 20 pounds but with very little physical evidence. This seemed likely to be untrue. Continued acupuncture treatment largely as a "feel good" and also to treat symptoms as they arose. Raised the issue of weight loss intermittently as she felt ambivalent about drugs but did not want to commit to herbal regimen.

Notes

In TCM parlance we say "damp is difficult to eliminate." We would expect a problem of this much damp to be highly intractable. Perhaps this reflects the psychic nature of damp as well, vhen it is being used as a form of protection. This kind of patient is very likely to bolt as soon as the treatment starts to move around all that "sludge" at a deeper level. This patient was willing to stay so long as we were perceived to be working symptomatically at a superficial level. But if the Chinese medicine was seen as a threat to the armoring and protection the weight afforded, and the denial necessary to maintain the whole psychological system, she backed off quickly. (It is interesting that the drug regimen combined appetite suppressants with a valium-like drug.) It should be remembered that many women with this severe a weight problem have issues of sexual and other abuse in their back ground. This kind of weight problem is very difficult to treat for these reasons.

Case #2

Patient was a woman 36-years-old who presented with primary complaint of irregular periods which had been occurring every 14-21 days for 4-6 months. Flow was fairly normal, 5 days, beginning heavier and tapering off. Medical revealed no abnormalities. Patient had been recommended to go on birth control pills to regulate periods. Accompanying symptoms were extreme thinness (117 Ibs, 5' 8" tall). Had struggled with underweight and inability to gain weight life long, but condition had worsened after birth of second child and 4 consecutive years of nursing two children. Other symptoms: fatigue, some appetite suppression, insomnia, irritability, breast tenderness, latter two symptoms worse just before onset of period. Craved sweets. Diet quite good but almost entirely vegetarian. Some constipation unless regulated dietarily. Strong Shen. Demeanor not dull. Color good. Tongue: pale with teeth marks. Pulse: very thin, slightly rapid, weak.

Syndrome Differentiation

In Chinese medical terms this is a fairly simple case of Spleen qi and blood deficiency. The Spleen deficiency is creating the fatigue, slightly poor appetite, and the irregular periods (Spleen unable to control the blood). The blood deficiency is affecting the Heart causing insomnia and irritability. There is evidence of Liver qi stagnation causing the premenstrual symptoms irritability and breast tenderness. This stagnation may also be contributing to the irregular periods. With regard to the issue of weight, despite her extreme thinness, this woman did not show signs of eating disorder. Her constitution had always been thin, but her problem had been exacerbated by the exhaustion of qi and blood from two births and long-term nursing. She was well aware of her weight problem, had a realistic sense of her body size, was able to report her eating habits and diffculties with ease. She showed no resistance to making necessary adjustments, including dietary ones, to treat her problem. (Of course, in this culture it is much easier on the psyche to be underweight than overweight.)

Treatment Principle

Tonify Spleen qi and Heart blood. Dispel Liver qi stasis ("Course the Liver")
Herbs: Gui Pi Tang, Jia Wei Xiao Yao Tang, Bao He Wan
Acupuncture: BL 20, BL 15, Sp 6, St 36, Lv 3, PC 6
Diet: Recommended the patient eat red meat at least two times a week.

Discussion

Herbs formed the primary aspect of this treatment with dietary changes next and acupuncture last. Gui Pi Tang was chosen to tonify Spleen qi and Heart blood. Jia Wei Xiao Yao Tang to move Liver qi. Bao He Wan to remove food stagnation and help digest meat for someone who is not used to it.

Acupuncture:

Treatments about every three weeks.

Results

Abnormal period was due one week from time of first acupuncture treatment. It did not occur at that time, however, but at exactly 28 days. Periods remained regulated for three cycles thus far. Energy improved. Sleep improved. Overate meat (once a day instead of 2-3 times/week as requested). Developed some indigestion. At this time Bao He Wan was prescribed and patient recommended to back off some on meat intake. Acupuncture treatments modified to dispel mild qi stagnation in the middle burner (St 25, CV 12, LV 14). Last two periods have been accompanied by breast tenderness, irritability and fatigue. Jia Wei Xiao Yao Wan dosage was increased before one period to no avail. Most recently a stronger formula has been substituted, Hua Yu Xiao Yao Wan. Between periods energy and all other symptoms remain good. Patient has gained about eight pounds during course of treatment and feels weight is still on the increase. This kind of weight problem should be easy to treat. In TCM terms there is very little damp stagnation. In psychosocial terms, this woman shows no sign of eating disorder, but rather a constitutional thinness made worse by life factors.

Case #3

Patient was a woman 38-years-old presenting with multiple complaints including severe nasal allergies to domestic animals and pollen, irritability, fatigue, depression, anemia, weight gain (6' 220 Ibs), extremely erratic appetite with episodes of voracious overeating. Patient had history of alcoholism with 12 years of sobriety. Felt she had an eating disorder or was at least severely sugar addicted. Eating problem most significant during ovulation accompanied by heightened sexual desire, irritabiiity and agitation. Struggle with weight was life long. Had been controlled on macrobiotic diet but returned after birth of only child. Patient remained largely vegetarian and tried to avoid dairy products. Diet was erratic, sometimes obsessively "healthy" other times heavily sugar, fat, and carbohydrate based. Pulse: rapid, large, slippery. Tongue: pale, slightly red tip, slight white coat.

Syndrome Differentiation

Stagnation of wind damp cold in the head with some wind heat as well and damp heat stagnation in the middle burner. In terms of her weight and eating, because of the damp stagnation, the patient perceives herself to be much heavier than she actually is. Because of severity of heat flaring up during ovulation, the appetite becomes intermittently voracious. Shame, embarrassment and influence of cultural values contribute to patient's exaggerated sense of the problem as an all-consuming addiction. Is this woman eating disordered? She does have somewhat unrealistic notions about proper body size for women (admires extreme thinness) and her own body size. Because of an underlying Spleen weakness, she easily becomes obsessed about weight, Her self esteem is very poor during periods of overeating. Her problem is different from Case #1 in that she is not in denial. In fact, she is overly conscious of her body and has an exaggerated notion of her weight and problem. To the extent that she is connected to the problem she is not eating disordered. To the extent that she is over-connected to the problem, she is imbalanced.

Treatment strategy

Treatment

Part I
Herbs

Acupuncture

Part II Herbs:
Acupuncture Diet
Recommended that patient eat more red meat especially during ovulation. We hoped that patient might be able to substitute some meat intake for extreme sugar craving. We have noticed empirically that many of our vegetarian patients seem to struggle with their sugar cravings more than other patients. We are experimenting with substituting meat to derive this energy.

Results
After two months of treatment under Part I regimen, allergies were essentially gone. Patient continued to live with domestic animals which did not cause a problem. "Pollen allergies" which had been constant, dissipated. Irritability significantly reduced. Allergies have not returned for 8 months. Treatment for Part II was delayed for personal reasons and for other intermittent health problems (stress fracture of the heel, colds, back pain); then resumed six months later. After two months of treatment patient noticed significant reduction in appetite to near normal during ovulation when on the herbs and noticeable return of appetite when off of the herbs during ovulation. Extreme sexual appetite decreased as well.

She had begun an exercise regimen and lost 20 pounds; energy and spirits were good. At one point we used some Spleen tonics to see if it was time for this approach. Her appetite sky-rocketed, so we returned to our original strategy. Heat clearing formulas improved the energy of this patient.

Notes

There are a number of interesting aspects of this case. First, as the allergies cleared, the "eating and weight" problem became much more a consuming issue for the patient. It was as if, as the upper heat and damp stagnation cleared, the original stagnation and heat became more noticeable and more active. Second, the patient's entire self image changed while on the herbs to clear the middle burner heat. She decided that "she was not an addict." She stopped obsessing about diet and forbidden foods. With our assistance she noticed the relationship between her ovulation and her eating for the first time in her life. She felt "normal" about eating, stopped indulging in highly Prohibitive diets and consequently her self esteem soared.

When she went off of the herbs the next month because of a cold, she immediately returned to her original impression that she was "an addict" who "could not be trusted" and so on. It is important to realize that her weight has held steady at 220 for over two years and that she gains only about five pounds during ovulation despite her excessive eating. This weight she promptly loses afterwards. Whether or not we label this patient " Eati ng disordered," she is quite treatable. She is motivated and is easily affected by Chinese medicine.

The questions are, can we keep her on the herbs long enough to break this a cycle and how long will it take? The longer it takes the more likely she is to become discouraged and return to her original image. The other problem is that the only other time she felt good about her body and weight was on a very strict (obsessive) macrobiotic diet. We must be aware of the possibility of substituting another ingested solution that does not actually fix the problem but becomes part of it. For many women with imbalances related to weight, the obsession with weight and body size is also an obsession with food or other ingested maladies/remedies. This is why severely prohibitive dietary regimens do not help, and may contribute to the problem.

Summary

These cases show a number of important issues. Although, weight is often not the problem for which the patients originally present themselves in the clinic, it often becomes central quickly, especially for women. We must be cautious to give attention to severe underweight, not only overweight, as the bias of the culture at large validates emaciation. Extremes of weight should at least alert the practitioner to the possibility of an eating disorder, especially if accompanied by unrealistic or unhealthy weight loss goals, insistence that the patient is fat when they actually are not, denial about severe weight problems, request for purgative herbs, lying about food intake, apparent obliviousness regarding extremes of weight, obsessiveness about weight and/or an inability to discuss eating habits in concrete terms. It should not be assumed that an eating disorder is present merely because of body size but rather body size combined with the above. In all three cases, weight played an important role in arriving at a diagnosis, but the significance of weight in the overall psychological picture of the patient was very different.

According to our teachers and our experience, the best way to treat "weight" is to ignore it and treat the presenting energetic picture. Healthy body size will automatically follow when the imbalances are corrected, unless the patient is so severely eating disordered that they cannot remain with the regimen. Patients of this sort are best recognized prior to beginning TCM treatment and referred for other kinds of psychoiogical support or counseling as well.


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