Pathology of Eating Disorders

From rail-thin models making fashion shows look like the liberation of a concentration camp to films like Supersize Me, we are a culture obsessed with food and fat. Recently the Norfolk and Norwich Hospital in the UK underwent a major revamping, installing new beds, trolleys, hoists and mortuary equipment that could handle patients weighing up to 450 lb, a response to the growing obesity epidemic. Meanwhile, children in American public schools are offered menus featuring corn syrup-sweetened chocolate milk, French fries and almost no vegetables. For some doshic types, severe eating disorders can result from poor habits instilled in childhood. Even the more resilient pitta types still have recourse to food addictions in response to forms of severe trauma that are prevalent in our society. Ayurveda's unique understanding of the different challenges encountered by different prakruti types enables us to help clients make appropriate and necessary changes more effectively than other modalities that use a 'one size fits all' approach.

Eating disorders, agni type and addictive allergies

Eating disorders are closely related to agni type, stress response and food allergies. An individual with visham agni can readily forget to eat, whereas one with tikshnagni has extreme difficulty in refraining from eating. Thus, a vata individual can quite easily develop a pattern of skipping meals and is also a candidate for anorexia nervosa. An individual with tikshnagni is likely to be a snacker, have a sweet tooth and potentially binge on sugar. It is harder to understand that someone with mandagni would consume inordinate amounts of food during the kapha time of the evening. However we should bear in mind that this person lacks experience of what true hunger feels like and is accustomed to eating from habit or for emotional reasons. In terms of stress response, the visham agni type is typically a stress under-eater. Pitta, tikshnagni types are fairly stress resilient but may fall prey to the tendency to overeat. Mandagni types are stress overeaters who have long since learned to disconnect hunger and eating.

Agni type is also closely related to food allergies. In visham agni there is often a sensitivity to vegetable proteins, particularly soy. There can also be a difficulty in digesting heavy foods such as wheat and cow dairy, and there may be gluten sensitivity. In tikshnagni, there is often a sensitivity to sharp and sour items like yeast and blue cheeses, as well as hot, oily foods like walnuts. In mandagni, there is typically sensitivity to heavy, slimy, sticky foods such as wheat and cow dairy. In all of these situations, an addictive allergy may arise, such that the food the individual most craves is the one to which they are allergic. When taking a diet history, it is important to notice foods that are consumed habitually or excessively, as these may be pointers to a major food allergy.

In terms of food allergies, it is important also to note the individual's ethnicity .Those whose ancestors lived on the far side of the agricultural frontier have a greater chance of being gluten sensitive because they have not had enough time, ancestrally, to adapt to gluten grains. (1) "Those populations who have had the least evolutionary exposure to cereal grains (wheat primarily) have the highest incidence of celiac disease." (2) Among the foremost at-risk populations are American/Ashkenazic Jews, (3) followed by Northern Europeans. Indigenous populations (Native American, Hispanic) are also at high risk. (4) Hence it is extremely important to be aware of the close relationship between Celiac Syndrome (gluten sensitivity) ethnicity and eating disorders. The connexion between kapha prakruti and genetic factor of gluten sensitivity is one that would merit further study.

Patient A.
A twenty three year old vata woman had a ten year history of bulimia occurring at least once every day, following an episode of adolescent anorexia nervosa. Despite her vata prakruti, she was trying to subsist mainly on salads and lightly cooked vegetables. Her protein of choice was tofu and her only starch was crackers. Following a day of such a vata provoking diet almost designed to create visham agni, she spent her evenings binging on cookies, soy chips and hot chocolate, which she then threw up. Her binge eating disorder was rooted in an addictive allergy to wheat and soy as well as a pattern of visham agni and stress under-eating throughout the working day.

Patient B.
A thirty nine year old pitta woman was, paradoxically, a food consultant. She had a ten year history of bulimia, from which she had recovered, yet she still struggled with food cravings and issues about body image. He diet centred mainly on soy and bread and she constantly craved yeasted breads, saying "My perfect meal is bread and cheese." Her history is typical of tikshnagni with an addictive allergy to yeast. Sharp cheeses of course are another pitta allergen and tend to exacerbate tikshnagni. It is also worth noting that she consumed soy every day, often at every meal, another major allergen that could be contributing to provoking her vata.

Patient C.
A kapha social worker, thirty-five years old, weighed 230lb at only 5'6''tall, putting her at the 91st percentile for her gender, weight and height. She was addicted to sweet baked goods such as pastries, scones, cakes and cookies. The sweet, heavy, dense quality of such baked goods makes is a lethal combination for kapha. Lacking in protein and high in carbohydrates, such items trigger an insulin response which increases hunger. Her story is an example of an individual with mandagni who has an addictive allergy to wheat.

Patient D.
A forty three year old kapha woman weighed 220 lb at 5'6"--the 84th percentile for her age, height and gender. She was aware of being allergic to both wheat and cow dairy, and yet was unable to stop herself eating a bowl of ice cream most nights after dinner, an example of mandagni with an addictive allergy to milk. During Lent she gave up sugar and ice cream yet could not stop her basic food addiction, which immediately transferred to bread, her other addictive allergy being wheat.

Eating disorders, prakruti and gunas

The types of eating disorder are distributed doshically and are related to the gunas of that dosha. For vata, laghu, vishada and chala are particularly important. Almost universally, cases of anorexia nervosa seen in the author's practice are found in vata prakruti. Patients suffering with this condition are devoted to the laghu guna, trying to weigh far less than their optimum and to express an etheric quality. Anorexia nervosa is also closely related to vishada, their excess clarity expressing in an obsessive/compulsive and guilt prone approach to food and eating. The chala aspect of vata is seen in the alternation between anorexia and bulimia--described by one vata patient as "bouncing back and forth." Vata may suffer from "Binge and exercise", an eating disorder which is obviously related to the chala quality as well as to khara, since the form of exercise selected is usually jogging or running, which are far too rough for vata. We have also noted a vata disorder that could be called "Drive and binge," driving around from one chain store to another all evening to obtain foods to binge on.

Patient E.
An eighteen year old college student presented with severe underweight (laghu) as well as anxiety and nervousness. As a child she had experienced OCD symptoms (vishada) focussed on her stuffed animals. Her current weight was around 100lb at 5'7" putting her below the 4th percentile. Her optimum was 130 lb. She maintained this low weight both by exercising ferociously (chala) and by refusing to eat in her college dining hall, "I felt too anxious and didn't know how much food to take." She was experiencing visham agni symptoms such as constipation. She expressed concern about her grandmother's obesity and was also clear that she in some way equated thinness with excellence and intelligence (laghu, vishada).

Patient F.
A twenty-five year old woman had a vata-kapha dual prakruti. Her vata nature was compulsive (vishada) and identified with thinness (laghu), leading her to reject her kapha tendency to a full figure. She became anorexic at age 15, getting her weight as low as 90lb at 5'6", which put her below the second percentile for her age and height. She had a history of OCD starting at age 11, centering on fear of death and concerns about demons and Hell. Currently the OCD was focussed on food (vishada). She would feel a compulsion to eat certain items, such as Campbell's tomato soup, which she would have to consume despite her utter disapproval of non-organic foods. She said that she had an "internal fascist dictator." Her current manifestation of eating disorder was "fast and binge," (chala, khara). She would do the Master Cleanse fast for two weeks at a time, followed by a major binge, after which she would again feel compelled to cleanse. Her story is an excellent example of vata's chala and khara tendency to "bounce back and forth." We can also surmise that her kapha side may have found expression in binging.

Patient G.
A thirty one year old vata stripper and dancer complained of severe candidiasis that originated and was sustained by her "drive and binge" vata eating disorder. She spent her evenings driving from gas station convenience store to Seven Eleven to Dairy Queen to Taco Bell, eating gallons of ice cream, as well as burritos, cookies and muffins. Note the extreme chala situation of eating in the car as she drove to the next place to buy more food to binge on. Also note that despite her binging habit she weighed only 125lb at 5'9", whereas a kapha patient with a similar tendency to binge might easily weigh twice as much.

In the case of pitta, there is typically a misguided attempt to seek balance. The ushna, tikshna, amla and laghu qualities of pitta lead many a pitta individual of either gender to seek refuge in sweet foods that are shita, guru and manda. Unfortunately the attempt to seek balance through an inherently unbalanced food such as white sugar is doomed to failure, and a binging disorder may easily result. A majority of pitta individuals suffer at least from a mild eating disorder, "sweet tooth." Often pitta's sugar addiction is found in conjunction with a history of alcoholism, and/or marijuana addiction. We have also seen a number of pitta patients with bulimia, always as a result of severe sexual trauma such as rape. Our pitta bulimics differed from the vata bulimics in that they did not have a history of teenage anorexia preceding bulimia, as was typically the case with vata, nor did they swing into episodes of fasting or exercise abuse.

Patient H.
A thirty-one year old Hispanic woman with pitta prakruti had suffered with weight issues since high school, when she developed bulimia. Although she could not as yet recover memories of sexual abuse, she was in a high risk category due to growing up with an out-of -control alcoholic father. She also had many other markers of severe sexual trauma. Although she was no longer bulimic, she now suffered with a binge eating disorder, consuming large amounts of raw cookie dough once a week. She never cooked or ate recognizable food (such as a visible piece of broccoli), subsisting on protein shakes and protein bars. At 170 lb and 5'2" she was significant obese. Her Hispanic ethnicity was suggestive of a high likelihood of an addictive allergy to gluten. She presents an example of pitta being driven to bulimia and to continuing eating disorders as a result of sexual trauma.

Just as vata eating disorders are dominated by the gunas of vata, kapha eating disorders manifest attributes of guru, manda, shita, piccila and slakshma. Whereas vata will drive and binge, kapha will sit at home and binge from their own refrigerator, choosing sweet, smooth heavy foods and growing steadily heavier in weight and cloudier in mind.

Patient I.
A thirty-eight year old male kapha business manager complained of mandagni, obesity and a "blood sugar roller coaster." At 230lb and 5'11", he was at the 83rd percentile for his age and height. He was aware that all dense carbohydrates gave him immediate fatigue. His pattern was to eat starches such as wheat and rice until he felt 'comatose' (sthira, manda, picchila) and then to consume Coca Cola i.e. sugar and caffeine to get energy. Although dairy made him nauseous, he regularly binged on ice cream (shita, manda, slakshma, guru, picchila) "out of suger nal longing." He then became so cloudy mentally that he craved more sugar to "help my brain work." He is a prefect example of kapha choosing foods to binge on that exacerbate the gunas of kapha. Note also that he binges at home, quite unlike the 'drive and binge' vata disorder.

Chikitsa for eating disorders

Vata eating disorders are often difficult to manage because of the compulsive aspect, which can render patients quite recalcitrant. Often such individuals persist in their behaviour for years or even decades without seeking help. For example, a thirty-nine year old woman presented with a twenty-six year history of bulimia. Since the age of twelve she had been binging, throwing up and purging at least one a week, claiming that, "A demon makes me do it." She also suffered from Dissociative Personality Disorder. Both her severe eating disorder and her DPD resulted from a horrendously traumatic childhood evolving emotional and sexual abuse and incest since infancy. She did not return for follow up, as her other personality took over and blocked her attempt at healing.

Severe vata eating disorders would be best managed in an integrative inpatient setting where Ayurvedic chikitsa was included alongside other relevant modalities in a closely supervised setting. Until this takes place, it is important to address all dimensions of being in a patient with a severe eating disorder, providing access to counselling, group work, meditation and relaxation as well as nutritional and herbal therapies. Patient E, for example, greatly reduced her anxiety, and hence her eating disorder, by learning to meditate, and patient A was advised to join Overeaters Anonymous, a Twelve Step program.

On the other hand, the mobile quality of vata can promote healthy change in an individual who is indeed ready to heal. One 'drive and binge' sufferer changed her life simply by changing her brand of chocolate to one that had no white sugar. Without the 'bingeable' effect of white sugar, she found it easy to limit her consumption to one ounce a day. "I was in Wal-Mart," she proudly announced, "and I got hungry, but I realized that nothing in Wal-Mart was edible. Before I found Ayurveda, I used to drive there to get things to binge on."

The strength of Ayurveda in working with any eating disorder is that we can offer not only nutritional guidance regarding avoiding allergens and bingeables, but also can take practical steps to pacify the dosha involved through a wide variety of therapies. As vata is calmed through the use of suitable dosha pratyanika herbs, as well as with oleation and sudation, the need to engage in a vata-driven eating disorder will inevitably diminish.

For pitta, education is crucial, for pitta thrives on information. A pitta individual with a mild eating disorder simply needs to understand that there are other ways to provide the sweet, cooling effect they desire. Fruits, for example, contain ample roughage and so are difficult to binge on compared to ice cream or M&Ms. Again, by the use of dosha pratyanika herbs, mild purgation and a proper regimen to manage tikshnagni, the sweet tooth can be modulated to a more normal level.

However, for those who have a long history of bulimia, significant damage has been done to the delicate tissues of the oesophagus and stomach. In our experience, even with the best use of herbs to heal these tissues, there is likely to be a long term impact on digestion. A mild, pitta soothing diet and regimen will be necessary on a permanent basis, to mitigate the damage done.

In the case of kapha, eating disorders and obesity are so closely interwoven with allergies to gluten and cow dairy that they often disappear instantaneously once those foods are eliminated from the diet. It is also important, again, to pacify kapha and rehabilitate agni in order to make permanent changes possible.

With all doshas, it is important to emphasize slow, steady, sustainable changes. Patient H, for example, was asked to take an organic microwaveable meal for lunch rather than just a protein bar. Although this is a far cry from an Ayurvedic lifestyle, it is a significant step towards eating recognizable food. She also agreed that she and her husband would cook one meal a week. Patient D changed her meal plan to make lunch her main meal rather than just grabbing a can of soup. This strategy helped her feel less hungry at night, her typical binge time.

Ayurveda has a tremendous amount to offer to those who suffer from eating disorders. As we have seen, extreme imbalance of one or more doshas and disordered condition of agni provide the drivers for the eating disorder. Thus by bringing balance to the doshas and rehabilitating agni we can address the deep roots of the distressing condition and provide the potential for health.

  1. Genetic and anthropologic factors in gluten-sensitive enteropathy: Warren Strober, American Journal of Physical Anthropology Volume 62, Issue 1 , Pages 119 - 126
  2. "Cereal grains: humanity's double-edged sword." Loren Cordain Ph. D. (1999) World Review of Nutrition and Dietetics, vol. 84, pp. 19-73.
  3. Celiac disease among Ashkenazi Jews from Israel. A study of the HLA class II alleles and their associations with disease susceptibility Tighe MR, Hall MA, Ashkenazi A, Siegler E, Lanchbury JS, Ciclitira PJ. Human Immunology 1993 Dec;38(4):270-6
  4. Dr. Michelle Pietzak: Poster Study presented at 10th International Conference on celiac disease research. This study showed an 8% incidence of gluten sensitivity in the sampled Hispanic population, far higher than the 1% incidence in the population at large.

Published in Conference Proceedings of 2007 NAMA Conference

