The Skinny: Western and Ayurvedic Treatment Approach To Anorexia Nervosa. By: Leah Kaplan

   Anorexia Nervosa, the mental disorder in which individuals consciously starve themselves, remains one of the most complicated mental illnesses present today. From its first appearance in Medieval Europe to its current form, anorexia nervosa continues to baffle those who study it and destroy the lives of those stricken with it. It remains so elusive for a few reasons. One, there is no reliable source as to what causes the disease. Research shows some genetic link, and trauma seems to be involved somehow, but evidence remains loose as to how exactly those factors affect the development. The public is inclined to lay blame on the media and current ideals of female thinness, but if this were the cause the entire population would be struggling, as we are all exposed to those images and messages. Secondly, while the three medical criteria discussed in this paper, a body weight of 85% below the ideal, an intense fear of gaining weight, and amenorrhea, are consistent amongst anorexic patients, all other symptoms and signs are variable. Some patients will present with depression and apathy, while others will struggle with excessive exercise and OCD behaviors. One woman might show signs of developing osteoporosis, while another has no symptoms of this at all. As many individuals as contract anorexia, that is how many expressions of the disease there will be. This fact lends itself to Ayurveda, India’s ancient system of wellness, which views each individual as completely unique and in need of a unique healing recommendation to match. Finally, while anorexia is very much a mental disorder, the physical symptoms cannot be ignored or put on the back-burner while the mental body is attended to because of the dangerous nature of the disease. It is the most deadly amongst mental disorders and must be handled with a level of seriousness to match. For this reason, Western medical science, with its abundance of research, seems more trustworthy and capable of handling treatment. By examining what both Western medicine and Ayurveda have to offer, one can develop strategies across modalities to increase healing and well-being for these patients and form a more complete picture of all that is needed to take care of an anorexic patient. 

   Anorexia Nervosa (AN) is defined in the DSM-V, the American Psychiatric Association’s (APA) classification and diagnostic manual, as having three criteria:

  • 1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health; 2. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight; 3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.  

   As one can discern from this lengthy and somewhat objective criteria, anorexia nervosa is a complex and complicated disease, both to diagnose and to treat. This becomes even clearer when one considers that the origin of this disease is psychological in nature, but unlike other common psychological disorders, becomes visible primarily because of physical habits and changes. These physical changes then perpetuate the psychological changes. In their guide, Eating Disorders: Everything You Need to Know, Jim Kirkpatrick and Paul Caldwell sum up this vicious cycle, “the psychological and emotional changes initiate the physical ones, but then the physical changes reinforce the negative psychological changes.”  The complexity of this cannot be overstated. From a treatment perspective, the question then becomes which do you consider first? Whatever therapies are administered to heal physical ailments as a result of starvation must also concern themselves with their psychological effects on the anoretic. And although the disease needs to be eradicated at the level of the mind, the physical body needs to be re-fed in a most literal way, as soon as possible; according to the National Association of Anorexia Nervosa and Associated Disorders (ANAD), “20% of people suffering from anorexia nervosa will prematurely die from complications relating to their eating disorder,” making eating disorders the most fatal of any mental disorder.   But treatments that might prove extremely effective for the physical symptoms of anorexia nervosa (such as severe weight loss and amenorrhea) might be useless here due to non-compliance on the part of the anoretic. Physical treatments cannot wait for the slower, more gradual process of psychological rehabilitation, which can take years, however: the re-feeding process must occur simultaneously to the psychological treatment for both bodily and mental health. As this paper proceeds to examine the Western and Ayurvedic treatments for the three medical criteria necessary for a diagnosis, this point of view will be considered for all possible therapies. 

   Classical Ayurveda does not mention anorexia nervosa, as we understand it today, as a disease condition. The origins of anorexia nervosa can be traced back to religious fasting in Medieval Europe and the reported starvation of female saints, the most famous being Catherine of Siena (1347-1380), who “claimed to be incapable of eating normal earthly fare.”  And the first medical reports of anorexia nervosa did not appear until 1689 in Thomas Morton’s “Wasting Disease of Nervous Origins.”  Considering that the Classical Ayurvedic texts were written between 500 and 1500 BC,  it becomes obvious why it was never mentioned: it probably did not exist. Anorexia nervosa seems to appear only after food becomes abundant and eating becomes less about survival and more about a social obligation or sensory pleasure. As Joan Jacobs Brumberg, the author of Fasting Girls: A History of Anorexia Nervosa comments in a New York Times article entitled “Anorexia: It’s Not a New Disease,”  “Anorexia nervosa emerges in cultures that are food-abundant…You don’t have anorexia nervosa in the third world: what you don’t eat, someone else will.”  While the specific disease anorexia nervosa is not mentioned in the Classical Ayurvedic texts, anorexia nervosa would be classified as manasika arocaka or “loss of appetite due to factors of the mind”  and for management of anorexia due to psychic origin, the Cakradatta recommends that “the patient is managed with pleasing and agreeable items.”  It is important to note the significant difference between anorexia, meaning loss of appetite, and anorexia nervosa, the disease described above. While this paper will address loss of appetite as it appears as a symptom in advanced stages of anorexia nervosa, it is a deep misunderstanding to think that the anoretic has lost her appetite or does not desire to eat. “Individuals with anorexia nervosa may eventually develop a true lack of appetite, but for the most part it is not a loss of appetite but rather a strong desire to control it that is a cardinal feature. Rather than lose their desire to eat, anorexics, while suffering from the disorder, deny their bodies even when driven by hunger pangs…”  writes Carolyn Costin in her reference manual, The Eating Disorder Sourcebook. Thus, loss of appetite will be considered as a late-stage symptom and not a causative factor. 

   In fact, the etiology of anorexia nervosa is still very much debated. It is beyond the scope of this paper to thoroughly investigate this topic, but trauma, genetics, a perfectionistic, self-critical personality, the influence of the media, and participation in competitive activities that have an ideal weight have all been found to be contributing factors.  Due to the size and scope of this paper, descriptions and treatments will focus only on post-menarche females, who account for 85-95% of all cases.  This is not to suggest that anorexia nervosa does not also affect males and older women. Additionally, there are as many symptoms and expressions of AN as there are patients. While this paper will only focus on three of them, it is worth noting that other symptoms will be present and can frequently include: dry skin and hair, the development of lanugo (fine hairs on the body to conserve heat), insomnia, fluid retention, decreased ability to concentrate, dullness in the mind, depression, social withdrawal, and apathy.   

   The first medical criteria required for a diagnosis of AN, as determined by the APA, is a “refusal to maintain body weight at or above a minimally normal weight for age and height…leading to body weight less than 85% of that expected.”  It is reasonable to say that all other symptoms are a cascade that originate from this one source. The refusal to maintain body weight is not due to lack of hunger, as previously noted, “but, rather, due to strict denial of that most basic of body instincts: hunger.”  So, while symptomatic relief is available and will be discussed for other medical complications, to treat the physical root of anorexia nervosa is to begin a process known as re-feeding. Re-feeding can happen either through working with a nutritionist and team of doctors while the patient lives at home or at an in-patient clinic, either at a private institution or in the psychiatric wing of a hospital. Throughout this process, Western treatment places primary importance on the calorie level and number of exchanges (measures of carbohydrate, fat, and protein content) present in the patient’s diet. A 2013 study conducted by the University of California, San Francisco, examined caloric intakes for adolescent anoretics: “Current recommendations for re-feeding in anorexia nervosa (AN) are conservative, beginning around 1,200 calories to avoid re-feeding syndrome.”  Re-feeding syndrome is “the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally).”  So one can see that there is a standardized caloric starting point for all anorexic patients. As Erin Naimi, R.D., eating disorders specialist and nutrition therapist commented in an interview for this paper, “things are pretty non-individualized in terms of how much [food]” is given to anorexic patients in treatment. This recent study completed by UCSF concluded that higher calorie diets with phosphate supplementation actually reduced hospital stays and resulted in faster weight gain with no incidents of refeeding syndrome.  This is very much against the current model of refeeding at Western treatment centers, who use “the strategy called ‘start low, advance slow.’”  Calorie increases from the baseline are dependent upon how quickly the anoretic gains weight. In a hospital setting, “there is a baseline meal plan which is the same…someone who needs to gain more weight would increase to a more rigorous meal plan,” says Ms. Naimi. But while immediately beginning with a higher calorie level might have physical benefits, like faster weight gain, there are psychological factors to consider; in the New York Times article, “Protocol to Treat Anorexia Is Faulted,” a patient who underwent rapid weight gain during her first hospital stay was so traumatized by it that she immediately lost all the weight as soon as she got out. When she was re-hospitalized two years later, she stayed for a longer period with slower weight gain and no such ramifications in the future.  Complicating matters further, anorexics will frequently experience hypermetabolism during the refeeding process. A 2012 study found consistent “evidence of a hypermetabolic state in patients with AN during refeeding which cannot be attributed to increased body mass alone…This is a phenomenon which appears to be unique to AN patients.”  This phenomenon requires caloric levels to increase rapidly and dramatically if the patient is to keep gaining weight. Increase levels too fast, however, and patients may experience “digestive disorders like constipation, diarrhea, and reflux disease. They may vomit involuntarily because the stomach and digestive capacity is diminished.”  The refeeding process shows exactly why treating AN remains a delicate matter; quantity of food must be balanced with rate of weight gain and digestive capability in equal measure, with the focus also being shared by the mental health of the patient. 

   Food choices in an inpatient program will vary from program to program, Ms. Naimi, the eating disorders specialist in Los Angeles, reports, but generally are not seen as important as caloric levels. In a strict hospital setting, the food provided for eating disorder patients is of the same quality as the food provided for all the other patients in the hospital. This usually means conventionally grown, highly processed, low quality ingredients. Foods are simple, bland, and dense, with the emphasis on the quantity of calories and number of exchanges rather than the specific foods used to deliver those measures. The strictest eating disorder programs will not even make accommodations for food allergies or vegetarianism. Other privately-run programs offer patients “up to three likes or dislikes, but draw the line around veganism, generally,” says Ms. Naimi. The ability to select foods from a menu is sometimes given as a privilege after the patient has gained a certain amount of weight and can be trusted to make her own meal choices. Upon arrival to an in-patient program, the anoretic does not possess the mental capacity to choose foods that are healthful for her and even more than that, cannot be trusted to make food choices that are not the direct result of the disease. This is the thinking behind stripping away any and all “preferences,” which might just be a thin veil for her disorder to control her food choices.  More than anything, the lack of information available on this specific subtopic speaks volumes as to how little attention is paid to food choices for the recovering anoretic. 

   In terms of food habits, the recovering anoretic’s entire day is structured around mealtimes and snack times. Interestingly, routine is of primary importance; breakfast, lunch and dinner are served at the same time everyday in in-patient programs. In Ms. Naimi’s experience, meals are timed so that patients finish their meals in a “normal” amount of time, with consequences if they are unable to do so. This usually means 30 minutes for each meal and 15 minutes for each snack. Ms. Naimi has never encountered a program that incorporates spiritual practices such as prayer into their mealtime routines, especially at larger, hospital in-patient centers. She says that smaller, private institutions will offer more spiritual practices, but not necessarily around mealtimes. The patients will always be monitored during meals and snacks, either by a nursing staff or by their own private therapists. These practices vary from program to program. The idea is two-fold: one, anoretics, especially at the beginning, are essentially at the mercy of their disease and will try anything to not eat, so monitoring prevents them from getting out of eating; and two, especially with a therapist, the mealtime becomes a sort of therapy session, where the doctor can see the patient interact with her meal and help her deal with the thoughts and behaviors surrounding it as they arise. Following mealtime, patients will typically have some form of therapy to help them process anything that came up during the meal or quiet time to relax, journal and practice stillness after eating.  

   From an Ayurvedic perspective, as explained in the Astanga Hrdayam, “consuming of insufficient quantity of food does not help improvement of strength, growth, and vigour, it becomes a cause for all diseases of vata origin.”  Thus, the first symptom of AN, weight loss resulting in a body weight of 85% of the ideal, is an invitation for vata vitiation, and treatment would therefore be centered around vata pacification: 

  • The treatment of (increased) vata are – oleation (internal and external), sudation (diaphoresis), mild purifactory therapies (emesis and purgation), ingestion of foods which are of sweet, sour, and salt taste; warm-oil bath massage of the body, wrapping the body with cloth, threatning (frightening), bath (pouring of medicinal decoctions, water, etc on the body), wine prepared from cornflour and jaggery (molasses), enema therapy with fat (oil), and drugs of hot potency, adherence to regimen of enema therapy, comfortable activities, medicated fats of different kinds (sources) prepared with drugs causing increase of hunger and improving digestion; especially anuvasana basti (oleation enema) prepared from the juice of fatty meat and oil.

   We have concluded that weight loss due to insufficient food qualifies as a vata imbalance and as noted above, the Astanga Hrdayama indicates the sweet, sour, and salty tastes as best for pacifying vata. So, a diet rich in these three tastes should be best for the recovering anoretic. Other qualities known to pacify vata are heavy, moist, oily, and warm foods. Refeeding according to Ayurveda follows samsarjana karma and recommends that the anoretic begins eating “the heaviest food that is well digested.”   In stark contrast to the non-individualized Western treatment approach, Ayurveda begins by tailoring the amount of food taken in to the specific digestive ability of the patient. If the patient is found to have deficient digestion, the Cakradatta recommends taking “hot rice-scum mixed with hingu and sauvarcala. By this the irregular fire becomes regular and the mild one is intensified. The rice-scum has eight properties – it increases appetite, cleans urinary bladder, gives energy, promotes blood, alleviates fever and pacifies kapha, pitta, and vata.”  Other foods like rice water, thin rice gruel, and rice porridge are also recommended as starting points to assess digestion by. Ghee and oils are added in small amounts to the food, beginning when the patient can properly digest rice, and then increased as digestion can tolerate.  Warming dipanas and appetite increasers, like Ginger, Pippali, Amalaki, and Chitrak should be taken with all meals, as well.  Ginger is especially recommended for low agni in the Cakradatta, “(In case of mildness of fire) taking pieces of fresh ginger with salt in the beginning of the meal is always wholsome [sic]. It stimulates digestive fire, cleanses tongue and throat and is pleasant.” In addition to dipanas, herbs can be used to help increase weight and improve appetite, while improving the psychiatric condition of the patient. Dr. A. A. Mundewadi, Chief Ayurvedic Physician at Mundewadi Ayurvedic Clinic in Maharashtra, India, recommends Ashwagandha, Shatavari, Samudrashosh, Jayphal, and Khurasani Ova for this purpose.  In addition, he, along with other sources, recommends the jam Chyawanprash to help with weight gain. No references to specific caloric levels can be found in modern Ayurvedic treatment plans for AN, an indication that the health of the digestion and pacification of vata are to be given more attention than the caloric level. While the goal of treatment is the same (weight gain), Ayurveda seems to prioritize healthy digestion above the speed with which weight is put on.

   Following principles of Ayurveda, more important than even the choice of foods that the anoretic is eating would be the way in which they are prepared and the way in which she is eating them. In the context of AN, these food habits become even more critical to counteract the anxiety that peaks with mealtimes. According to the Charaka Samhita, “food should be taken mindfully…food should not be taken when afflicted with grief, anxiety, confusion, fear, anger, passion or greed…Food should be taken under conducive and pleasant environment. The individual should be relaxed and happy.”  Ayurvedic treatment would extend off the plate and into the very room in which meals are being held, encouraging the use of all five senses to make eating a more pleasant experience. Aromatherapy may be administered before a meal, to stimulate digestion, during a meal to calm anxiety, and after a meal to promote relaxation in the mind and reduce digestive upset. Ginger, Mandarin, and Lavender, respectively, are all indicated. Color therapy on the walls of the dining-room or as a light source can also be recruited to aid the healing process. Sattvic colors like gold, green, and blue are all indicated. In addition to these recommendations, “food should be taken when hunger is felt and not delayed or taken in a hurry or very slow.”  While hunger cues are guaranteed to be distrusted at the beginning, meals can certainly not be taken in a hurry or very slowly. This seems particularly applicable to anoretics who will want to rush mealtimes to get them over with or draw them out to avoid eating. Taking an appropriate amount of time encourages mindfulness and connection of the mind to the body. 

   In addition to maintaining a body weight that is less than 85% of the ideal, a patient must display an “intense fear of gaining weight or becoming fat…and a disturbance in the way one’s body weight or shape are experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight.”  This symptom moves the disease from the physical body into the deeper layers of the mental and emotional bodies, what would be considered the manomaya kosha and vijnanamaya kosha in Ayurveda. Western treatment for this fear, anxiety, and misperception incorporates psychotherapy and, to a lesser extent, medications. The use of medications is solely focused on symptomatic relief of psychological symptoms, such as anxiety, and not on the root cause of the disease. As reported by the Mayo Clinic, “there are no medications specifically designed to treat anorexia because they haven’t been found to work very well. However, antidepressants or other psychiatric medications can help treat other mental disorders you may also have, such as depression or anxiety.”  The most common medications used to treat mental symptoms stemming from AN are anti-depressants, specifically Selective Serotonin Reuptake Inhibitors and anti-anxiety medications, like benzodiazepines. Research shows that the time of administration significantly alters the effectiveness of SSRI’s. Fluoxetine (Prozac), an SSRI, for example, has been shown to prevent relapse in anoretics, but only when given after weight restoration.  Benzodiazepines, on the other hand, are best administered “when therapeutic efforts are made to counteract the pursuit of thinness and ritualistic behaviours [sic] around eating,”  it was reported in a study published in The Journal of Psychiatry and Neuroscience. Further, from the same study, “despite their merits in the acute treatment of anorexia nervosa, benzodiazepines are used sparingly in clinical settings. This may be because psychotherapy, accompanied by nutritional and behavioural approaches to healthy eating and weight gain, is considered the most promising treatment.” We can conclude, therefore, that while appropriately administered drugs can be helpful in reducing relapse, the initial healing is not accomplished through pharmaceuticals. Nutritional and behavioral approaches are administered in the form of therapy, both personal and group, and through nutrition therapy and education. As far as therapeutic approaches go, cognitive behavioral therapy has been found to be most effective, generally, and even more effective than nutrition counseling. A 2003 study published in The American Journal of Psychiatry found that “cognitive behavior therapy was significantly more effective than nutritional counseling in improving outcome and preventing relapse.”  This can be attributed to the fact that it is not lack of knowledge about nutrition that is causing the anoretic to starve (on the contrary, eating disorder patients frequently display an encyclopedic knowledge of caloric contents and dietary facts), but the mental disturbances caused by the disease. 

   Fear and anxiety like the kind displayed by anoretics would, from an Ayurvedic perspective, fall squarely under the category of vata vitiation. Specifically, prana, vyana, and samana vayu would all be vitiated in the manovaha srota. To treat this vitiation in the mind, Ayurveda provides a great variety of body therapies, lifestyle practices and herbs. As cited earlier in the Astanga Hrdayam, both external and internal oleation are strongly indicated to pacify vata in the body, as well as in the mind. In his text, Ayurvedic Healing, Dr. David Frawley recommends sesame oil massage for anorexia, with emphasis on the head and feet of the patient, as well as the administration of sandalwood oil to the head.  Even though he is referring to anorexia meaning loss of appetite, the remedies are applicable, as they are designed to pacify vata. This external oleation will pacify vyana vayu as well as slow the rate of absorption of prana vayu, decreasing the speed at which thought flows through the mind and thus calming anxiety. In addition to this therapy, shirodhara, known for its effectiveness in reducing anxiety, insomnia, and nervousness would be of huge benefit to the anoretic, too. This external oleation would be best complemented by internal oleation as well, however, this brings up some of the complexities that are inherent in this most complicated disease. Firstly, agni in the advanced stage will be low, perhaps too low to digest oils without creating ama (as explored previously in this paper). Secondly, the anoretic is almost guaranteed to strongly resist taking in pure oil, which she sees as pure fat, to the point that it creates more anxiety than it is worth. Anuvasana basti, as previously recommended in the Astanga Hrdayama, would be an excellent way to apply oil internally in order to pacify vata at its root, the colon. And because it would not need to be ingested through the mouth, this internal oil application might be easier for the anoretic to swallow, as well as being of excellent benefit. Additionally, lifestyle practices that would be recommended include yoga, meditation, and time in nature. Yoga is of particular importance for several reasons. As Patricia Walden, yoga teacher, writes in the book The Woman’s Book of Yoga and Health, “besides offering emotional and spiritual support, yoga provides physiological help to reverse or minimize the long-lasting effects of starving.”  Physically, yoga postures can balance the endocrine system and blood pressure, calm the adrenal glands, and even jumpstart menstruation.  Almost more importantly, though, yoga can arrest the sympathetic nervous system response, a fight-or-flight mechanism that will frequently kick in for an anoretic during and right after mealtimes, when anxiety is highest. Gentle, slow, flowing sequences that are designed to pacify vata by including lots of poses that encourage compression of the solar plexus will have the additional benefit of providing a new habit that, hopefully, in time, will replace the old starvation patterns. A 2010 study completed by the Department of Adolescent Medicine at Seattle Children’s Hospital shows very promising results; the authors of the study concluded that individualized yoga sessions decreased Eating Disorder Examination scores after 12 weeks of practice and also significantly reduced food preoccupation immediately after the practice.  Finally, herbal remedies are available to treat anxiety; nervine sedatives will calm vata in the mind, while nervine tonics will build the strength of the nervous system. Dr. A. A. Mundewadi recommends “Jatamansi, Shankpushpi, Vacha, Kushmand, Brahmi, and Sarpagandgha [to treat the psychological component of anorexia nervosa].”  

   The final symptom that will be examined in this paper is amenorrhea. This criteria was recently removed from the DSM-V, the most recent version of the APA’s manual, but because of the large number of anoretics who experience amenorrhea and because of the seriousness of such a symptom, I have chosen to include it in this report. Amenorrhea is defined by the Mayo Clinic as “the absence of menstruation – one or more missed menstrual periods. Women who have missed at least three menstrual periods in a row have amenorrhea.”  “From a traditional Western medical perspective, the loss of menses due to AN is viewed as a result of low hormone levels, specifically a lack of luteinizing hormone and follicular-stimulating hormone precipitated by inadequate body fat or low weight which causes corticotropin-releasing hormone to be suppressed.  But, recent studies, like the one from the Department of Pediatrics at the Schneider Children’s Hospital at the Long Island Jewish Medical Center are finding that “resumption of menses require[s] restoration of hypothalamic-pituitary-ovarian function, which [does] not depend on the amount of body fat.”  And a 2006 study by the University Tor Vergata in Rome, Italy, found that “an adequate body composition and a well represented fat mass are certainly a necessary but not sufficient condition for the return of the menstrual cycle.”  Very few studies have been conducted around treating the hypothalamic disturbance that seems to be at the root of the persistent amenorrhea. A 1976 study entitled “Amenorrhea in Anorexia Nervosa: Assessment and Treatment with Clomiphene Citrate” concludes that in patients who were still amenorrhoeic following the finding of normal LH levels, “that they have a persistent hypothalamic disorder whereby the normal midcycle peak of LH secretion does not occur. A hypothalamic disturbance has long been postulated as the cause of pituitary hypofunction in anorexia nervosa, but definite evidence has been lacking.”  Due to this lack of research, Western medical treatment focuses on hormone replacement as the answer to amenorrhea, if menses has not resumed following adequate weight gain. It is recommended that patients who present with amenorrhea be placed on oral contraceptives for the health of their bones, which are already under duress from malnutrition. Osteoporosis is one of the major health concerns facing anoretics because bone density loss is believed to be irreversible and amenorrhea is seen as a major causative factor in osteoporosis. Thus it is of primary importance to replace the hormones artificially to protect the health of the bones. The common treatment plan is to keep the patient on oral contraceptives until weight is restored and then observe if menses returns. If it does not, then the patient would be placed back on oral contraceptives. As the lack of research in this area shows, the priority for AN patients is to get hormones back into the body as quickly as possible to protect the stability of the bones; amenorrhea is really only viewed as an issue if the woman wants to get pregnant, at which time they will provide medications to stimulate ovulation. 

   Following in line with all the other symptoms before it, from an Ayurvedic perspective, secondary amenorrhea of this sort is considered a vitiation of vata in the rasa and shukra dhatus of the artavavaha srota. The shukra dhatu is the deepest dhatu of the body, so nutrition must be digested first by all six other dhatus before it can reach and nourish the shukra dhatu. Thus the treatment of amenorrhea begins with the treatment of dhatu agnis and regulation of the digestive system of a patient. Ayurveda understands that even if adequate nutrition is being taken in, the tissue being produced could be of low quality if there is disturbance in the dhatu agnis. The Cakradatta suggests a “suppository made of iksvaku (seeds), danti, pippali, jaggery, madana, yeast, madhuyasti and snuhi latex and kept in vagina” to induce menstruation.   If not this, then another alternative remedy is suggested, “Japa flower mixed with sour gruel or jyotismati leaves, both fried, and rice-cake of durva – woman taking any of these gains menstruation.”  As Dr. Frawley notes for treatment of amenorrhea, “an anti-vata or tonifying diet is primarily indicated using dairy, nuts, oils, whole grains and other nourishing foods.”  This is right in line with the diet discussed previously to restore the weight of the anoretic. Dipana herbs to regulate any digestive disturbances would also be indicated here. Herbs may also be used to promote menstruation, if necessary. Reproductive tonics like Shatavari, Ashwagandha, Vidari Kand, and Wild Yam are all indicated. Chyawanprash, as mentioned before, would be an excellent herbal supplement for amenorrhea. Ayurveda also recognizes the role that stress plays in amenorrhea. “Excessive motion such as a fast-paced lifestyle filled with travel, stress and overwhelm is a key contributing factor [to amenorrhea],” as is excessive exercise.  Other vata-pacifying therapies like abhyangha, shirodhara, and appropriate yoga (as previously discussed) would also come into play as treatments for stress-related amenorrhea. Restorative yoga as well as Yoga Nidra would be the preferred types of yoga. Even sleeping during the day should be considered as a remedy, as suggested in the Cakradatta, “sleeping during the day is recommended in the following conditions – those who are exhausted by exercise…patients suffering from diarrhea [sic], abdominal pain, dyspnea, thirst, hiccough, and vatika disorders; those who are emaciated…”  The other aspect of amenorrhea that cannot be denied is in the mind of the patient. If the eating disorder serves the function of keeping maturation and adulthood at bay, then the patient will actually desire to lose her menses. This must be dealt with on a psychological and spiritual level through therapy and self-study.

   In summary, I believe that neither Western nor Ayurvedic remedies provide the entire answer to this mysterious and dangerous illness. Rather, it seems that a treatment plan which encompasses the best of Western science along with the holistic, individualized healing therapies of Ayurveda would provide the most well-rounded and complete approach with the best possible chances of achieving recovery. Due to the severity of advanced cases of anorexia, it would be irresponsible to depend purely on Ayurveda as a healing modality; there is much more evidenced-based research around a Western refeeding model to support its use in providing nutrition to malnourished individuals safely. But for healing not just the body, but also the mind and the spirit, Ayurveda can absolutely supplement Western prescriptions. Since medications have been found so ineffective in treating AN, perhaps both providers and patients will feel more open to alternatives like herbal treatments and body therapies. And as the trend towards more conscious eating keep moving forward, one can only hope that eating disorder programs will pay more attention to not just how much, but what they are feeding their patients. Ayurveda, I believe, can be especially helpful in the treatment of amenorrhea, since the condition seems to still baffle Western medicine and appears to have so much to do with lifestyle and stress reduction. Imagine a hospital program that offered regular yoga instruction, had a meditation space, offered abhyanga and shirodhara, and encouraged reverence, rather than rigidity, around mealtimes: such a place would encourage not only the healing of bodily tissues, but the mending of the very soul itself, which can be just as starved for attention as the body it inhabits. Ms. Naimi has already seen a trend towards bringing in spiritual practices in smaller, private residential treatment centers and in private practices, so maybe the larger inpatient centers will follow suit. This would require a rethinking of the anoretic as an individual with a disease, rather than as a disease that has taken over an individual. And that can only result in deeper levels of healing and understanding of this still elusive and devastating disorder.

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