Reference
Wei D, Janszky I, Fang F, et al. Death of an offspring and parental risk of ischemic heart diseases: a population-based cohort study. PLoS Med. 2021;18(9):e1003790.
Design
Observational study
Participants
The subjects of this study were the parents of live-born children recorded in the Danish Medical Birth Register from 1973 to 2016 (n=2,807,548) and the Swedish Medical Birth Register (n=6,711,952) from 1973 to 2014. Mean age of these parents at baseline was 31 years, and 53% were women. A total of 126,522 (1.9%) parents lost at least 1 child during the study period.
Study Parameters Assessed
Using several nationwide registers, investigators analyzed data on Danish and Swedish parents who had lost a child due to natural or unnatural causes; they used Poisson regression for the parents’ subsequent risk of ischemic heart disease (IHD) and acute myocardial infarction (AMI).
Outcome Measures
Investigators tracked the incidence of IHD and AMI using nationwide registers.
Key Findings
Bereaved parents had a significantly higher risk of IHD and AMI than the nonbereaved (incidence rate ratios [IRR; 95% confidence intervals, CI]: 1.20 [1.18–1.23], P<0.001, and 1.21 [1.17–1.25], P<0.001, respectively).
These associations were present not only in case of losses due to cardiovascular disease (CVD) or other natural causes, but also in the case of unnatural deaths. The AMI risk was highest in the first week after the loss, when it was over 3 times higher (IRR [95% CI]: 3.67 [2.08–6.46], P<0.001). There was also a 20% to 40% increased risk observed throughout the whole follow-up period.
Practice Implications
Loss of a child may be the most significant grief any person can experience in life. It comes as no surprise that bereaved parents experience a decline in physical and mental health.1 They utilize healthcare services more, call in sick more often, miss more work, and report more sleep problems than nonbereaved parents.2 There is no doubt that grief is a major stress; it is hard on people and hard on their health.
Past research has demonstrated an association between grief and dying of cardiovascular disease. Loss of a spouse may be the best-studied bereavement, and it is well-established that spousal bereavement leads to a period of heightened cardiovascular risk for the surviving spouse. Parkes reported this association in widowers as early as 1969.3 Since then, the association has been seen in multiple studies. The immediate weeks after bereavement represent the highest risk period for both men and women across all ages. The increased risk occurs whether the spouse’s death is expected or unexpected. While high levels of social support offer some degree of protection,4 losing a spouse increases risk of death in the survivor from almost any cause, in particular cancer, infection, and cardiovascular disease.5
In a 2007 study by Hart et al that followed 4,395 married couples (aged 45–64 years), after the death of a spouse, bereaved participants were at higher risk of dying from any cause (RR 1.27; 95% CI 1.2–1.35). Relative risk of death increased for cardiovascular disease, coronary heart disease, stroke, all cancers, lung cancer, smoking-related cancer, and accidents or violence. After adjustment for confounding variables, RRs remained higher for bereaved participants from all these causes except from lung cancer. There was no strong statistical evidence in this particular study that the increased risks of death associated with bereavement changed with time after bereavement.6
It may be that those experiencing prolonged grief are the people at greatest risk for cardiovascular risk rather than the cause of the grief itself.
More often though, the studies have suggested that risk is higher immediately after bereavement and then lessens over time. Carey et al, in a UK study from 2014, followed 30,447 people who had lost a partner and who were matched with similar but unbereaved controls; they reported that “Within 30 days of their partner’s death, 50 of the bereaved group (0.16%) experienced an MI or a stroke” compared with 67 of the controls (0.08%) during the same period (IRR, 2.20).7 Risk of MI more than doubled (IRR, 2.14) and risk of stroke increased nearly 2.5 times that of the control group (IRR, 2.40). Bereaved women were at greater risk than men during the first 30 days (IRR, 2.93 vs. 1.65) but the risk equalized between sexes during the first year of bereavement.7
The impact of the death of other significant people on mortality has only recently been the subject of scientific scrutiny.
A 2002 study by Liong Ji et al may be the earliest report of an association between the death of a child and increased risk of MI (N=19,361). Risk of a fatal MI increased by 36% for bereaved parents.8 These same authors went on to report in 2003 that among the same cohort of bereaved parents, there was no increase in risk of stroke9 or, in a 2004 report, that there was no increased risk of inflammatory bowel disease (IBD).10
The death of anyone dear increases risk of a MI. In 2013, Mikael Rostila reported that even the death of an adult sibling was associated with increased risk of death from MI, particularly among women (HR, 1.25 for women vs 1.15 for men). If that sibling died from MI, the associations were stronger, HR for women 1.62 and men.11
Yet, from these scattered data, it is not clear whether the relative risk of death changes with the intensity of the emotion experienced. Researchers have ranked the experiences of grief by intensity from the more to less intense and reported that the grief of bereaved parents > bereaved spouses > bereaved adult children.12
The assumption is that “The grief experienced by parents is more intense and prolonged than grief experienced following the death of other family members.”13 Children are expected to outlive their parents; the disruption in this natural order can destroy parents’ hopes and dreams for the future. A child’s death may also profoundly change parents’ roles and sense of self as responsibilities of caring for their now-deceased child are removed.14
The intensity of parental grief is thought to be due to the close and enduring relationships parents assume that they would have with their children. Although one might predict that the ill health caused by bereavement might follow a parallel path, the worse the grief the worse the decline in health, the data so far do not appear to support this idea.
Instead, research is focusing more on the process of grief and how people go through the experience:
“The grief experience is not a state but a process. Most individuals recover adequately within a year after the loss; however, some individuals experience an extension of the standard grieving process. This condition has been identified as complicated grief or prolonged grief disorder, and it results from failure to transition from acute to integrated grief. Symptoms of acute grief include tearfulness, sadness, and insomnia and typically require no treatment. Intense grief over the loss of a significant person may trigger the acute onset of myocardial infarction (MI). The impact may be higher for those with higher cardiovascular risk. Complicated grief has prolonged symptoms of painful emotions and sorrow for more than one year. Complicated grief has also been termed as, ‘prolonged grief disorder,’ ‘persistent complex bereavement disorder,’ ‘pathological grief’ and ‘traumatic grief’. Both the ICD-11 and DSM-V have approved diagnoses of ‘prolonged grief disorder.’ All of these conditions depict intense, impaired, and prolonged grief. Patients show a preoccupation with the deceased and feel inner emptiness, no interest in life, and sleep poorly. There is a correlation between complicated grief and acute coronary syndrome (ACS). It has been estimated that 7-10% of those bereaved do not adapt to the loss and, in turn, develop complicated grief.”15
It may be that those experiencing prolonged grief are the people at greatest risk for cardiovascular risk rather than the cause of the grief itself.
Note that most of these parent bereavement studies were conducted in Scandinavian countries. In such developed countries pediatric and neonatal death are relatively uncommon, <1% compared to 4.3% globally.16 It should also be noted that while rare today, infant mortality was once common. From Paleolithic times until the mid-1700s, about 30% of live births did not survive past childhood. Average lifespan hovered at about 35 years. This only began to change in about 1750 in Great Britain and only among the aristocratic class. It is believed that due to the introduction of variolation and a reduction in smallpox deaths among the aristocracy. No improvements in lifespan occurred in the middle or lower classes. Even just a century ago, in 1900, up to 30% of infants in some US cities still died before reaching their first birthday.17 In the United States in 1915, an average of 10% of infants died in their first year of life.18 In evolutionary terms child bereavement was a common, almost expected experience. But now because this is a more-rare experience, the family and friends of bereaved parents are usually unprepared to anticipate and respond to the bereaved parents’ needs. Insufficient social support may increase the parents’ vulnerability to complicated grief. This may in turn leave them more vulnerable to health complications from their grief.
What might the role of clinicians be in cases of bereavement? Perhaps the most important thing to understand is that caring for bereaved parents is not something to take on alone; it takes a team of people to provide the emotional safety net that these people will need. Reach out to the other health providers involved to be sure that the parents have been referred for appropriate grief counseling and support. This is such a focused specialty, so reach out and ask for help.
Of course, there are certain interventions that most integrative doctors will think of and consider as adjunctive aids. The homeopathic repertory is rich in remedies listed for “ailments from grief.” Many of these cover the symptoms described in the new diagnostic description of “complicated grief.” A few are also prescribed for cardiac conditions.
In the botanical pharmacopeia, we often think of extracts of Hawthorne berry (genus Crataegus) as both supportive of cardiac function and healing of emotional injury. Another consideration might be the traditional Chinese combination of Hawthorne berry and Polygonum cuspidatum, a formula known as Huzhang-Shanzha, which is commonly prescribed for congestive heart failure.19
Any food or medicine rich in flavonols might also be a candidate. Chocolate, of course, comes to mind immediately. There is strong evidence that chocolate consumption is associated with lower risk of death from CVD. An umbrella review of meta-analyses published in June 2019 by Veronese et al reported that “Among observational studies, including a total of 1,061,637 participants, the best available evidence suggests that chocolate consumption is associated with reduced risk of cardiovascular disease (CVD) death (n=4 studies), acute myocardial infarction (n=6), stroke (n=5) and diabetes (n=6).”20
The study by Baynham et al published in March 2021 (which Princess Burnett, ND, reviewed recently in this journal) suggests that high-flavonol chocolate attenuates the impact stress has on the heart. Their results reminded me of JK Rowling’s Harry Potter books and how her characters used chocolate as an antidote for experiences of terror.21 Rather than thinking of chocolate as a daily supplement, perhaps its use is more appropriate as an ad hoc antidote to severe stress.
