Historical Theories on Treating Obesity with Chinese Medicine

Cover of Huang Di Nei Jing Su Wen

Historical theories

Chinese Medicine has a long history, and I’ve searched through the commonly known sources from its origins to the present day for any info on the treatment of obesity. This blog post will cover the pre-modern ideas I’ve found.

The Nei Jing

First, we start with the Nei Jing (“Yellow Emperor’s Inner Classic” – 黄帝内经) which was compiled between roughly 300 BCE to 220 CE (Unschuld, 2003, p. ix). I consider this text to be the primary source of all Chinese Medicine theory, even in the modern day. It consists of two books: the Su Wen (“Basic Questions” – 素問) and the Ling Shu (“Spiritual Pivot” – 靈樞).

The only mention it makes of obesity directly is when discussing (what were most likely) Mongolians, in which it said of those who lived to the West, “Its people enjoy rich food and they are fat.” The commentator, Wang Bing, said that rich food here likely referred to koumiss (a fermented dairy product), meat, and bones (Unschuld, 2011, p. 213). So, there is primarily an association of “rich food” in the diet with being overweight, with dairy and animal products possibly being some of the types of “rich food”. In Chapter 31 of the Su Wen, meat is mentioned as a food that causes heat, and is prohibited when clearing heat from the body (Unschuld, 2011, p. 497). This is likely due to the fact that animal products contain more fat, and as we will see in a bit, fat was thought to increase internal heat. So, we can definitely count meat as a “rich food” that could have been thought to add weight to the body.

Changing one’s diet was considered necessary for treatment of obesity in the Nei Jing. One disease that they identified was called “heated center and wasting center”, and the treatment required abstaining from rich food. It was mentioned that this happens in wealthy people, and that such people won’t enjoy hearing that they have to change their diet in order to be cured, and that treatment will therefore be difficult (Unschuld, 2011, p. 606-607). Another section mentions that if the patient is well nourished and wealthy, various diseases which they present with are most likely caused by their diet of rich food (Unschuld, 2011, p. 476).

The Nei Jing spoke of “spleen solitary heat disease”, which to me seems very similar to the “heated center and wasting center” I mentioned earlier. In this case, the patient has a sweet taste in their mouth, which is caused by excessive “fat and delicious food” in the diet. As a result, this turns into “wasting and thirst” disease (Unschuld, 2011, p. 695-697), which is a disease that shares some symptoms with the modern Western disease of diabetes, such as abnormal hunger and thirst, and perhaps emaciation (Brutsaert, 2019). As we know from Western Medicine, raised BMI (obesity) is considered a major risk factor for the development of diabetes (Obesity and overweight, 2018), so it’s very interesting that this correlation between diet and what may have been diabetes was made approximately 2,000 years ago or more. The Nei Jing says, “this person must have frequently consumed sweet and delicious food, and his diet was mostly fat.” Besides rich food, now we also have sweet food as a culprit.

This section of the Nei Jing differentiates between sweet and fat foods. “Sweet food lets man have central fullness.” “A fat diet lets man experience internal heat.” Central fullness is similar to the modern Chinese Medicine diagnosis of phlegm-damp, which is the primary culprit in obesity; and heat is thought in modern times to be capable of creating phlegm or dampness by coagulating healthy body fluids. So, both sweet and fat foods are problematic when it comes to weight loss. It’s interesting to note that excess fat in the diet is thought to generate internal heat, because it’s common knowledge that fat contains 9 calories per gram, compared to protein or carbs, which both contain 4 calories per gram. Also, considering that fat contains more than twice as many calories as protein or carbohydrates, that means fat consumed in the diet is twice as likely to cause weight gain due to the increased amount of calories. Fat should be kept at a moderate level.

For this disease being discussed, which was perhaps similar to diabetes, “Lan” was mentioned as an herb which could “eliminate the old qi” and treat it (Unschuld, 2011, p. 697). The modern Materia Medica says that the herb “pei lan”, especially if fresh, might be used for this, although it’s unclear if this was the exact herb that the Nei Jing was referring to (Bensky et al., 2004, p. 477).

We explored how diabetes might have been discovered in the Nei Jing, but the text also mentions “chest pains” resulting from sweet flavor foods (Unschuld, 2016, p. 574-575). Heart disease, where chest pains can be experienced, is another major risk factor that can develop due to increased BMI/obesity (Obesity and overweight, 2018). This matches up with more recent trends in Western nutrition research, which strongly correlate refined carbs and sugars to increased risk of heart disease (Temple, 2018).

It’s important to note in Temple’s research that whole grains and cereals in moderate amounts seemed to prevent heart disease. There are fad diets currently for weight loss, such as the Ketogenic diet, where carbs are cut out entirely, and some research suggests that these types of diets can potentially increase one’s risk of heart disease by 50% (Norton, 2018). Clearly, it’s unnatural to avoid all carbs, and it’s important to get at least some whole grain varieties of them. It’s important to note that the Nei Jing doesn’t say to avoid grains or the sweet flavor entirely.

In Chinese herbal medicine, “gua lou xie bai ban xia tang” is used to treat chest pains due to phlegm (Scheid, et al., 2009, p. 515-516), which in Chinese Medicine theory, can be a byproduct of excessively sweet flavors. It could potentially be therapeutic in some cases of coronary heart disease, or simply when a person has had a poor diet and has chest pain as a result.

Why does sweet flavor contribute to obesity? The Nei Jing says simply, “The sweet flavor moves to the flesh; in the case of diseases in the flesh one must not consume sweet flavor in large quantities.” (Unschuld, 2011, p. 406-407). We can just think: excessive sweet flavor creates excessive flesh (it makes sense with what we know about high fructose corn syrup and its strong relationship to obesity). It’s unclear if the Chinese Medicine thinkers of this time differentiated between adipose/fat tissue and other types of fleshy tissue; it was all just called “the flesh”.

“If dampness causes harm, it harms the flesh. (…) If sweet flavor causes harm, it harms the flesh.” (Unschuld, 2011, p. 109) Here we can see that the Nei Jing spoke of obesity as a state of the flesh being harmed; to have excess fat is not a healthy state of the flesh. Regarding lifestyle, the text also said, “To sit for a long time harms the flesh.” (Unschuld, 2011, p. 410) This is obvious to us today, since we know that a sedentary lifestyle without activity is a prime cause of obesity. So, besides reducing excessively sweet flavors in the diet, the Nei Jing also recommends increasing activity in one’s life for the treatment of obesity.

Is there a difference between a good sweet flavor and a bad one? Yes, in Chapter 5 of the Su Wen, it’s said essentially that the various flavors nourish, but excessive flavors harm (Unschuld, 2011, p. 98-99). An example of a nourishing sweet flavor could be a food like rice when in moderation, whereas an excessive sweet flavor would be cane sugar. If you simply taste one and compare it to the other, you’ll be able to easily discern which one is “excessive”.

“Sweet flavor generates the spleen, the spleen generates the flesh (…) If sweet flavor causes harm, it harms the flesh.” (Unschuld, 2011, p. 108-109) This section of the Nei Jing seems to imply that the spleen becomes excessive as the sweet flavor becomes excessive, and that in turn makes the flesh excessive. Taken together with, “The spleen longs for sweet flavor” (Unschuld, 2011, p. 188), we can see the correlation with cravings for sweet things, or a “sweeth tooth”, and obesity. We could surmise the treatment for a sweet tooth – simply eat less sweets, and you’ll crave them less eventually. But if you eat more of them, you’ll likely end up craving them more.

It’s thought in modern Chinese Medicine that a major cause of obesity is “qi or yang deficiency”. This is where there isn’t enough activity in the digestive system, or not enough transformation and transportation, to process the food. So, it turns into phlegm-damp, which enters the flesh and makes the person bigger. But in some cases, there isn’t a deficiency of qi or yang, and the person becomes overweight regardless. This can sometimes be due to simply having too much sweet flavor in the diet.

“Sweet flavor relaxes.” (Unschuld, 2011, p. 399) Relaxation here can imply a lack of movement, or a lack of yang. So, constitutionally the person might be perfectly balanced and have a healthy and active digestive system, have healthy yang, but if their diet consists of too much excessively sweet flavors, it will slow down while that sweet food is digesting, creating phlegm-damp, and eventually, fat will be increased. Sweet flavor needs to be in the right balance with other flavors and types of food that promote digestion, such as bitter vegetables.

“Sweet flavor enters the stomach. These qi are weak and few. They are unable to ascend and reach the upper burner. When they remain in the stomach together with the grain, they cause the stomach to be soft and moist.” (Unschuld, 2016, p. 574-575) This again is just revealing that excessively sweet flavors cause a lack of transportation, or activity, in the digestive system, leading to dampness and phlegm.

With all of this talk about excessive sweet flavors being bad in the case of obesity, what is recommended instead? “When the spleen suffers from dampness, quickly consume bitter flavor to dry it.” (Unschuld, 2011, p. 385) The bitter flavor can be considered to be a good addition to the diet for obesity, because it directly addresses the pathogenic factor which is correlated to obesity – dampness. The acrid flavor can also be used, although the Nei Jing doesn’t mention it directly. The Tangye Jing said, “Use pungent (another word for acrid) flavors to purge the spleen”. (Dell’Orfano & Fruehauf, 2015)

Lots of vegetables are bitter tasting – for instance, spinach. Ginger is an example of something that’s acrid, pungent, or spicy. When Chinese Medicine practitioners think about herbal medicine to address phlegm-damp, they will often think about bitter and acrid herbs. For instance, the formula wen dan tang, which treats phlegm conditions, has bitter zhi shi, and acrid zhi ban xia.

In modern Chinese Medicine, many practitioners will think about “tonifying the spleen qi” when treating obesity. This is because the spleen is responsible for transformation and transportation of food, and they’re correct in thinking that the qi of the spleen will help in doing that. But ren shen is one of the primary herbs to tonify spleen qi, as demonstrated in the formula si jun zi tang, and it’s a very sweet herb and formula.

In the Tangye Jing, there are formulas that tonify and formulas that reduce for the spleen. The tonifying formulas contain ren shen, and are said to treat “inability to metabolize food” and “emaciated physique”. They could potentially help a skinny person gain weight, with the sweet herb, ren shen. The reducing formulas are said to treat “spleen qi excess”, “internal cold”, “abdominal distention and fullness” (Dell’Orfano & Fruehauf, 2015), all of which could be thought to correlate with obesity. So, the spleen reducing formulas could potentially address obesity, with the acrid herb, fu zi. Another example of an acrid herb used in the treatment of obesity is cang zhu, used in the slightly more modern formula, ping wei san.

So, practitioners should be clear about the use of different flavors of herbs and foods when treating obesity. We should be cautious with sweet herbs and foods, and try to think of bitter and acrid ones more often. Having a sweet herb like ren shen, or a sweet food like rice, as the primary force in our treatment, will have the opposite of our intended effect. But how often do we think about rice congee when we think of a food that drains damp? Very often – that’s a common concept in modern Chinese Medicine. Perhaps we should be thinking about leafy greens primarily, which are normally more bitter tasting, and keep the rice (or any grain) in more moderate portions. Perhaps in a less liquidy form, as well.

Similarly with acupuncture: perhaps many practitioners know that certain acupoints drain damp or transform phlegm, and they use them, but our needling style in the US is often very gentle. It’s relaxing, like the sweet flavor. Gentle needling is tonifying. We’re taught correctly that in order to reduce a point, it has to stimulated strongly, which has an effect more like acrid flavors… but we don’t want to cause our patients pain. However, if we want our weight loss treatments to be effective, perhaps our acupuncture needs to be in line with our treatment principles, and not having the opposite of the intended effect. At the very least, we should insert upon inhalation and withdraw upon exhalation without closing the point, for reducing.

“Because beverages and food are doubled, the intestines and the stomach are harmed.” (Unschuld, 2011, p. 645-646) I’m sure we’ve all experienced overeating during the holidays, and then feeling heavy, fatigued lethargic and tired, foggy headed, bloated, etc. Instead of thinking that means we’re “full”, we should realize that those are all symptoms which our bodies use to tell us that something is wrong; they’re symptoms of phlegm-damp, which is really like a toxic byproduct of poor digestion. We ate too much, usually too fast. “The people of old, those who knew the Way (…) their eating and drinking was moderate.” (Unschuld, 2011, p. 30-32)

In modern Chinese Medicine, we often think of bao he wan for helping us feel better when we overate during the holidays. But the best solution is to always eat moderately. “When a disease is in the spleen (…) abstain from (…) overeating, from damp earth, and from soggy clothes.” (Unschuld, 2011, p. 389-390) A simple way to abstain from overeating, which requires strong discipline and willpower to do, is to chew 30-50 times per each bite of food. It helps us predigest the food with salivary enzymes prior to reaching the stomach, and also helps us to slow down, which enables our appetite signals to work better: we realize we’re not hungry anymore when we’ve eaten enough, rather than after we’ve eaten way too much. It’s my opinion and experience that a major cause of dyspepsia (indigestion) is simply not chewing well enough, and eating too quickly.

Regarding some dietary trends in the treatment of obesity: lately, intermittent fasting has become popular. Here’s what the Nei Jing says about fasting, “Man requires water and grain as his basis. Hence, once man is cut off from water and grain, he will die. Once the vessels contain no stomach qi, death is imminent, too.” (Unschuld, 2011, p. 317-318) “Not eating for half a day weakens the qi, and for a full day nearly depletes it.” (Unschuld, 2016, p. 525) When the Nei Jing mentions death, it can generally mean something more like a poor prognosis rather than the person’s life actually ending. It says that the qi, and specifically the stomach qi, is weakened from having no food. Well, one of the causes of obesity in modern Chinese Medicine is “qi deficiency”! Perhaps with intermittent fasting, the person is losing weight due to having less food, or less time that food is taxing the digestive system (which can be a great thing), but in the long run it might have a negative effect on one’s metabolism. This can mean weight loss during the periods of time that you’re doing intermittent fasting, but weight potentially coming back even more than previously once you stop eating that way.

With Chinese Medicine, we want to try to treat obesity while maintaining a strong metabolism, so that the weight doesn’t come back. We have to tonify the qi and yang, if they’re deficient, to ensure that the metabolism stays healthy and the weight stays off.

Sun Simiao

After the Nei Jing, we move on to Sun Simiao (孫思邈), who lived from 581-682, reaching the ripe age of 101 (Yi, n.d., p. 1). According to Sumei Yi, while Sun was alive there wasn’t that much of a focus on weight loss, perhaps because emaciation from malnutrition was a bigger issue.

In his chapter on nutrition from the “Recipes Worth a Thousand Gold” (備急千金要方) most of the foods he discusses are for the purposes of putting on weight (Yi, n.d., p. 5). But this chapter does contain a little bit of relevant information – it speaks of overeating as causing an enlarged abdomen, shortness of breath, susceptibility to severe illness, and diarrhea (Yi, n.d., p. 10). Like I said, there’s not much info on weight loss here, but Sun’s writing does agree with the Nei Jing about not overeating, and reveals a couple of symptoms which would let a patient know when they’ve done it (enlarged abdomen, shortness of breath or not being able to breathe as freely, and diarrhea).

Li Dong-Yuan

Next in history is Li Dong-Yuan, who lived from 1180-1251 CE (Flaws, 2004, p. vi). What might be the first real discussion of obesity in Chinese Medicine history is in his book, “The Treatise on the Spleen and Stomach” (Pi Wei Lun). He describes two reasons why a person might become obese, and also a reason why a thin person who eats a lot doesn’t gain weight.

According to the book, one cause of obesity is being healthy but simply overeating. Gradually, that causes fat to accumulate. The other cause of obesity according to Li Dong-Yuan was spleen and stomach qi deficiency. For this deficient type of person, despite eating normal and small/moderate amounts of food, they still gain or maintain extra fat. Sound familiar? This is thought to happen because “the spleen is replete and evil qi [i.e., phlegm dampness] is exuberant.” (Flaws, 2004, p. 17)

Modern students and practitioners of TCM might wonder how the spleen can be replete/excess, and also be deficient at the same time. We normally treat spleen qi deficiency by supplementing it with sweet flavors, like ren shen. But perhaps in this case, it means that sweetness within the body (foot taiyin dampness) is already excessive, and the spleen is deficient simply in being unable to transform and transport food into qi, blood, and body fluids. The food then turns into food stagnation, pathogenic water, dampness, and phlegm, all of which lead to weight gain.

For why a thin person who eats a lot doesn’t gain weight, Li Dong-Yuan said that this was due to “fire hidden in the qi phase of the stomach” which causes excessive hunger and eating large amounts of food, along with “spleen vacuity [leading] to withered flesh”. Furthermore, he says that “once the stomach is diseased, the spleen has nowhere from which to receive its supplies” (Flaws, 2004, p. 17-18).

So, an obese person might have spleen deficiency, but a thin person might also. A difference is that a thin person has stomach fire and the flesh doesn’t grow from the spleen, and that an obese person has fluid metabolism problems and the flesh grows due to pathogenic factors (phlegm-damp) from the spleen.

Zhu Dan-Xi

After Li Dong Yuan and the Earth school, which focused on the Spleen and Stomach, we move on to Zhu Danxi, who lived from 1282-1358 (Furth, 2006).

He said that heat in the stomach causes people to be easily hungered and desirous of excess food, but didn’t specify that it occurred only in thin people, like Li Dong-Yuan did (Yi Tian & Damone, 1992, p. 26). While Li Dong-Yuan said that healthy people who overeat and then become obese simply have an exuberance of original qi in the spleen and stomach, which is a good thing, it may alternatively be the case that these non-deficient overweight people could have stomach heat or fire, too.

Zhu Danxi wrote about “spleen yin”, which could probably be equated to what we think of today as spleen qi. Yi Tian and Damone write that “When the Spleen yin is injured, although the Stomach can receive food, it cannot be transformed and transported by the Spleen” (1992, p. 25). Zhu Dan-Xi also mentioned that rice was yin supplementing (Deadman, 2016, p. 129), so he probably meant the nourishing type of qi tonification, with sweet flavors like ren shen. When he says the spleen yin is injured, he’s talking about qi deficiency, which can be a cause of obesity as we found out from Li Dong-Yuan. When discussing rice as being supplementing for the yin, he says that it’s important to eat it together with vegetables, which are “able to course and free (the stomach) and make transformation easy.” (Deadman, 2016, p. 129) So he did understand that tonifying qi with sweet also required something else to make the sweetness move; perhaps he thought of vegetables as functioning similarly to bitter or acrid flavors.

Zhu Dan-Xi says that with spleen qi (what he calls “yin”) being deficient, “food is difficult to digest. Although the person eats, the food cannot be transformed into qi and blood. Because of the yin deficiency, and the inability of the qi to descend, the qi stagnation gives rise to phlegm.”(Yi Tian & Damone, 1992, p. 26) He gives reasoning for why spleen qi deficiency can cause phlegm-damp in the flesh – it’s because of stagnation from food not being transformed and transported, and just sitting there. It could be the case that a thin person doesn’t gain weight due to their spleen qi deficiency, while an overweight person easily does, because with the thin person perhaps their food is descending. But with the overweight person, the food sits there and stagnates, turning into phlegm-damp.

Zhu Dan-Xi also advocated for a certain type of diet (which I’ll cover more in a future section of this blog series) called the “qing dan” diet, which basically means clear and plain. His diet consisted primarily of plant based whole foods, such as: grains, beans, greens, and fruits, which have moderate and harmonious flavors. He thought that foods which people create by means of brewing and blending during the cooking process, in order to create stronger flavors, created toxins (Deadman, 2016, p. 149). For instance, he would probably not be a fan of something like soy sauce, or something like orange chicken. He also was said to recommend moderation in eating meat in his book, “The Treatise on Benefits of Plain Food” (Ru Dan Lun), as too much meat consumption would impair one’s health (Deadman, 2016, p. 142).

So, that concludes this section on the history of weight loss and obesity in Chinese Medicine. I’m sure there are more historical theories which exist, and that it’d be possible to dig much deeper into each of the well known sources that I’ve mentioned here. I plan on doing further research in the future, in order to gain even more clarity on this subject.

Reference List

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Unschuld, P.U. (2016). Huang Di nei jing ling shu: The ancient classic on needle therapy. Oakland, CA: University of California Press.

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Yi, S. (n.d.). Recipes worth a thousand gold: The food sections by Sun Simiao (Unpublished doctoral dissertation). University of Washington, Seattle, WA.

Yi Tian, N., & Damone, R. (1992). Zhu Dan Xi’s Treatment of Diseases of the Spleen and Stomach. Journal of Chinese Medicine, Number 40. Available from https://www.journalofchinesemedicine.com/

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