Live Well Live Long: Reflections on the Centrality of Nourishing Life Teachings in Chinese Medicine

I remember hearing long ago, or perhaps reading, that nourishing life (yangsheng) was a branch of Chinese medicine – alongside herbs, acupuncture, tui na, dietary medicine and so on. In fact, from then on I used to repeat this idea myself.

However, as time passed, and especially once I started work on my recent book a few years ago, Live Well Live Long: Teachings from the Chinese Nourishment of Life Tradition, I grew to realise that yangsheng is much more than this. In truth, it is the very foundation of our medicine.

How can I be so confident? I offer the Neijing Suwen (Yellow Emperor’s Inner Classic) as evidence. It’s generally true that books (non-fiction ones at least) lay their cards on the table in their opening pages, and chapter one of Chinese medicine’s most seminal text couldn’t be clearer.

Insights from the Neijing Suwen

The Yellow Emperor asks his adviser Qi Bo why in ‘ancient times’ people remained vigorous until even the age of a hundred, but ‘nowadays’ are exhausted and decrepit by the age of fifty. It’s simple, says Qi Bo: the ancients knew how to live. Their eating and drinking habits were moderate, they led a regular lifestyle and they modelled their behaviour on the interplay of yin and yang—they followed the natural order of things—but people nowadays drink alcohol “as if it were water”, indulge in unrestrained sex, and “have no clue as to what it means to hold on to satisfaction … they are all for gaining quick pleasures in their minds … the whole pattern of their lives, their rhythm of waking and sleeping, is completely without moderation or regularity. Thus they can’t even make it to fifty without going into decline”[1].

This passage is crucial for two main reasons. Firstly, and many centuries ahead of its time, it laid down the idea that health and sickness arise from natural causes rather than from the whims of gods, devils, evil spirits, and so on.

Secondly, while recognising that constitutional (genetic) inheritance and good or bad fortune play a significant role in whether people are strong and healthy or weak and sickly, the Neijing makes clear that lifestyle and behaviour, the only factors we have some control over, also have an enormous impact. By cultivating health and living wisely, it proposed, people were better able to resist acute exterior pathogenic diseases, the primary killers of the age, and reduce or delay the onset of chronic non-infectious diseases—the primary killers of our own age.

This is all the more important because every medical practitioner soon comes to learn that once serious chronic disease has developed, it is unlikely ever to be cured, only ameliorated. As a pithy Chinese saying goes, “medicine can only cure curable disease, and then not always”.

The same sentiment appears in chapter two of the Neijing. The ‘sages’, it says, did not intervene once disease had already set in, but before it took root. Delaying was compared to starting to dig a well when one was already thirsty, or only starting to forge weapons when the battle had begun to rage. Surely this would be too late.

The highest role of the doctor, the early tradition proposes, is therefore to be more than a technician—however valuable that may be. The physician is someone who informs and guides patients by teaching and modelling a healthy lifestyle. As a Chinese saying goes, “three parts medicine, seven parts nurturing health. Skill in treating is not as good as skill in nurturing health”.

The Growing Relevance of Yangsheng in Modern Healthcare

If understanding how to maximise health was important two thousand years ago, how much more vital is it today, when a tsunami of chronic non-infectious disease threatens to overwhelm health services worldwide. The incidence and associated costs of disorders such as diabetes, dementia, cardiovascular disease, cancer, depression, and stroke are predicted to rise to unmanageable proportions within the next two to three decades (with especially severe rises in the developing world as modern Western lifestyles take hold).

In the United States, for example, it is expected that 40% of the population will have some form of cardiovascular disease (CVD) by 2030, with an increase in healthcare costs from 273 billion dollars in 2010 to 818 billion dollars in 2030.[2] The World Health Organisation states unequivocally that 80% of CVD can be prevented by modifying diet, increasing physical activity, and stopping smoking.

All thoughtful observers understand that we cannot treat our way out of these challenges and that the future of medicine must be preventative. Indeed, we are already besieged in the media by health warnings and advice on diet, superfoods, new ways to exercise, mindfulness and more, but the information is often piecemeal, contradictory, and ever-changing.

This is where the Chinese yangsheng tradition can take center stage. It is tried and tested, refined over more than two millennia, and rooted in simple basic principles that draw all its parts into a coherent whole. Turning to these core principles also helps us make sense of many modern health challenges that were unknown to the ancients.

What is yangsheng?

Yangsheng (yang = to nurture or to nourish, sheng = life or vitality) has its origins in Taoism, Confucianism, Buddhism, the martial arts, and Chinese medicine, as well as folk wisdom—that rich repository of human knowledge, handed on from generation to generation. It aims to promote physical, emotional, and mental health and wellbeing, and holds the vision of an integrated body and mind, harmony and balance, with a healthy old age and a fitting death.

It addresses pretty much every aspect of human life, but it can be said that four topics are primary. These are:

1) cultivating the mind and emotions;

2) managing diet;

3) cultivating the body with work, rest, and exercise;

4) sleeping well.

These four can be compared to the legs of a chair. When all four are sound, the chair is stable, but if one or more is damaged, the chair becomes increasingly unbalanced.

As Ge Hong, the 3rd century alchemist, put it, “in all matters of nurturing life, one must widely hear and then embody the most essential things, broadly look and then choose well. The partial cultivation of one thing will not prove sufficient to rely on. Furthermore, one must be on guard against the tendency of specialists to tout the one thing they are good at”[3].

How often do we encounter people who exercise obsessively but eat badly, or eat meticulously but fail to exercise, or eat and exercise carefully but fail to get enough sleep or, most commonly of all, suffer stressful and emotionally chaotic lives?

I have listed cultivation of the mind and emotions as the first of the four legs for several reasons.

Firstly, unless we can achieve some degree of emotional integration, we simply cannot look after ourselves. We make resolutions that we fail to keep and undermine our best intentions, often acting in ways which actively harm us. As Sun Simiao, the great 7th century ‘king of medicine’, said, “whenever people don’t live out their lives or their life is cut short, it is always caused by not loving or cherishing themselves”[4].

Secondly, as we know from our study of Chinese medicine, extreme and persistent anger, fear, worry, anxiety, obsessive thinking, grief, and so on can directly harm us, giving rise to physical, mental, and emotional disorders. At the same time, we also know that repressing genuine emotional responses is equally harmful since it can give rise to stagnation, itself the cause of many diseases. Managing the emotions therefore requires an aware and subtle dance between these two extremes. And on top of this, of course, yangsheng also teaches that the active cultivation of positive states such as peacefulness, mindfulness, kindness, generosity, gratitude, happiness, and laughter can directly promote health and heal disease.

The third reason is that without cultivating these positive states, a preoccupation with personal health and wellbeing can easily become narcissistic or even exploitative, without care and compassion for our planet and its inhabitants. It is salutary to remember that the Nazi party in Germany promoted nature walking, environmentalism, tree planting, vegetarianism, homeopathy, organic agriculture and healthy exercise in the open air.[5]

Finally, however well we practice yangsheng, the time will come when our bodies show their age and our faculties diminish, marking the inexorable decline towards our ending. While sight, touch, smell, hearing, appetite, libido, vigour, sleep, and more take a downward path, there is one quality that has the potential to grow until our final moment, and that is wisdom. But true wisdom can only come from a lifetime of observation, learning, emotional honesty and cultivation of the shen.

Core ideas of yangsheng

Attuning our lives to the natural cycle

The natural world moves in an endless duet of yin and yang. The cycles of day and night, the four seasons, and the course of life itself follow the pattern of growing yang (dawn, spring, childhood), maximum yang (midday, summer, adulthood), growing yin (evening, autumn, mature reaping of life’s fruits) and maximum yin (night, winter, quietness, peace and ending).

The art of living, according to health cultivation teachings, is to harmonise with the way of nature, since we are as much a part of it as everything else is. We attune to the natural order of the day, for example, when we lead a regular life, rising with the light, becoming fully active through the day, slowing down in the evening and resting through the night. Our work, activity, relaxation, rest, and sleep are thus balanced and harmonious and if we are able—through luck or judgement—to be able to follow this natural way, we will be free from the harm caused by overwork, insufficient rest and sleep, and excessive inactivity.

More widely, recognising this playing out of yin and yang in the course of our lives, from birth through to old age, offers us a tool to better understand the mystery of life and death and our place in the natural cycle.

Harmonising yin and yang and following the middle way

In diet, we flexibly balance hot and cold foods and learn to manage fullness and emptiness. We combine light and easily digestible qing dan foods (grains, vegetables, fruits and legumes) with richer and more nourishing wei foods (fats, animal foods, and strongly-flavored and -seasoned food), according to our age, constitution, lifestyle, levels of physical activity, the climate, and our geographic location, avoiding excess of either.

In traditional body-mind-breath exercise (such as qigong and taiji), we balance fast and vigorous movements with slow and quiet ones, strength with softness. We learn how to be still and centered amid movement, and how to flow internally even amid stillness. We balance rooting and rising, inhaling and exhaling, opening and closing. We don’t drive ourselves to the point of exhaustion but follow the middle way, tuning our exercise so that we feel energised and vigorous throughout the day and from year to year. As Ge Hong said, “the body should always be exercised… yet even in exercise do not go to extremes”[6].

In physiological terms, these exercise traditions train the parasympathetic (rest and relax) nervous system through quietness and deep abdominal breathing so that we can stay in touch with our calm center even when in sympathetic (fight or flight) mode. It also helps us return to the parasympathetic state as soon as the demand is no longer there, rather than dwelling in high stress states—the bane of many people’s lives.

In our emotional life, as we have seen, we work to integrate emotional self-expression with emotional restraint; receptivity, sensitivity, and acceptance with will and determination.

Keeping it simple

The 19th century doctor Fei Boxiong said of medicine, “There exist no miraculous methods in the world, only plain ones, but the perfection of the plain is miraculous” [7]. This is true also of yangsheng. Rare and expensive medicines or foods may have their place when there is real disease, but in general it is the committed, steady and relaxed cultivation of the basics that delivers the goods—breathing well, eating well (in a sustainable way), training the body, sleeping well, spending time in nature and with friends and loved ones, listening to music and looking at beautiful things, drinking tea, enjoying (if we are lucky) a rich and rewarding sex life.

Stopping before completion

It is said that when any tendency reaches its extreme, it must inevitably turn into its opposite. As the Daodejing says, “better stop short than fill to the brim. Oversharpen the blade and the edge will soon blunt”[8].

In the internal exercise arts, we coil and uncoil, lengthen and release, over and over, often for long periods of time, but we never stretch to the maximum or exert ourselves to our limit. In diet, we remember the Chinese saying, ‘when eating, stop when you are seven-tenths full’, and we take care that a commitment to healthy eating doesn’t become too intense, but remains flexible, relaxed, and enjoyable. In some Daoist sexual teachings, the male partner is encouraged to stop before ejaculation.

In each of these cases the core idea is that an optimum state—physical vigour, keen appetite, clear intention and sexual desire—is maintained and not dissipated by taking it to its limit.

Free flow

If harmony of yin and yang is one definition of health in Chinese medicine, free flow is the other. In fact, this perspective is shared in Western medicine, which, although it has no concept of qi, fully understands how vital it is for blood to flow freely through the six thousand miles of major and minute blood vessels in the body—all of which have to remain open, relaxed, and flexible. Healthy free flow can be enhanced by many different activities: movement, alcohol, tea, sex, laughter, free self-expression, and more.

Exercise is one of the most important of these. As early as the 3rd century BCE, the Lushi Chunqiu (Annals of Lu Buwei) said that “if the body does not move then the essential qi does not flow. If this does not flow then the qi clogs up”.

Vigorous aerobic exercise quickly moves qi and blood by pumping the heart, lungs, and muscles, and can be a surefire way of making us feel vigorous and alive. Yet if our pre-exercise state was characterised by pent-up feelings or lethargy, we can easily revert to this underlying stagnation once the effect wears off. When mindful softening, relaxation, and awareness are integrated into exercise, however, we slowly train the body (and the vessels) to remain more continuously open to free flow.

In fact, it has recently been ‘discovered’ that sitting for long periods (irrespective of time spent in formal exercise) is harmful. I put ‘discovered’ in quotation marks, because, like many things modern science believes it has determined, all traditional cultures knew this. Sun Simiao, for example, wrote: “the Way of nurturing life consists of … never sitting nor lying for a long time,” while a thousand years earlier, the Annals of Lu Buwei, wrote, “going out, one uses a chariot; returning home one uses a sedan chair—people love these for the comfort they provide, but they should be called ‘mechanisms that make one lame’”[9].

The role of yangsheng in clinical practice

In the space available in this short article, it has only been possible to provide a brief overview of yangsheng. There is of course extensive detail that can be brought to every aspect of its teachings. In my opinion, this information should form a core part of the training of Chinese medicine practitioners.

Without denying the great challenge we face in helping patients improve their lifestyle (the bane of all health promotion efforts up to government level), we can still offer them invaluable information that will significantly help their chances of getting better.

There are a few points to note. The first is the common observation that giving advice can be fraught with unexpected consequences—often, for example, creating resistance and even an unconscious desire to do the opposite. In my own practice, I learned to follow the principle of simply offering information, allowing my patients the space to make a grown-up decision as to whether they wanted to put it into practice. If they did, I found that setting jointly discussed targets and keeping a written record (for example, of dietary changes, exercise frequency, etc.) could be helpful.

Secondly, we have one wonderful tool that isn’t available to other health practitioners, however well-intentioned: pattern differentiation. It is counter-productive to try to encourage someone to change every aspect of their lifestyle, but pattern differentiation allows us to better home in on the key problem areas. A patient with liver qi stagnation, for example, probably needs to move more and to express themselves more freely, while dietary changes may be less important—or even contraindicated given their likely tendency towards obsessive behaviour. By contrast, someone with yin deficiency usually needs rest and relaxation more than exercise, and a richer, more nourishing diet than a patient with phlegm or dampness. In the same way that diagnostic skill develops slowly with experience, so does the ability to home in on the key changes that can act as a tipping point for wider transformation.

The last point is that our biggest influence on our patients may be the information they pick up—possibly without even being aware of it—simply from their encounter with us. As I suggested above, a Chinese medicine doctor can be much more than a technician. We can aspire to be wise guides who model what it is to lead a balanced life. For this reason, we need to start by treating the most important patient of all: ourselves.