Month: September 2021

“The horse has left the barn.”

Those six words, said by my husband’s oncologist, changed our lives forever, although the sense of impending loss had begun weeks earlier with a blood test. There would be more tests, exams, and visits to specialists. As George and I waited for a definitive diagnosis, we bargained with ourselves and with the universe. When we finally met with the cancer treatment team to review all the tests, George’s 6-foot 2-inch frame struggled to fit into the space at the small table, where we strained to follow the conversation. Hearing the word metastatic — meaning cancer had spread throughout his body — was like fingernails on a blackboard.

But there’s no real way to prepare for grief, an inescapable feature of the human condition. Its stress following the death of a loved one can lead to physical illness: cardiovascular diseases, broken-heart-syndrome (takotsubo cardiomyopathy), cancers, and ulcers. Emotional distress often sparks physical distress known as somatic symptoms. How each person navigates grieving varies. Comfort takes different forms for different people. While my journey is individual, my story touches on universal themes, particularly for those grieving in the time of COVID-19.

Anticipatory grief strikes first

George’s diagnosis was advanced metastatic prostate cancer, spread to lymph nodes and bone. There would be no surgery. No radiation. No chemotherapy. Only palliative care.

Some days George wanted to talk only with me. Other days he wanted to talk with those who were “in the same boat.” He saw himself as washed up on the shores of a new, unknown continent. I felt washed up with him. The National Cancer Institute describes these feelings as anticipatory grief, a reaction that anticipates impending loss.

In time, we returned to everyday routines. Sometimes we laughed and didn’t think about his illness. George even conceived of and hosted an annual party for his best friends — men who would be his pallbearers — and their partners. The “pallbearer party,” as it came to be known, was a wonderfully raucous event. Grown men laughed until they cried. Each year, by the end of the night, I knew the tears were for anticipated loss.

George lived another 11 years, more than twice what was expected. But anticipating his loss did not cushion my broken heart.

Acute grief following a death

George died in May 2020, at the beginning of the COVID-19 lockdown. Despite the pallbearers’ dress rehearsals, there was no funeral, no gathering of loved ones. Nothing to soothe my overwhelming pain.

In those first few weeks, time seemed stretched thin, moments repeating themselves like musical notes on a scratched record. I felt untethered, unmoored, adrift. My sides ached from crying; my knees were unsteady. I don’t recall eating.

At the funeral home, when I saw George in a casket, the large room seemed bright from lights hitting the shiny wood floor. Later, I realized the room was much smaller and dimmer than I remembered, its floor not shiny but covered by oriental rugs. Burgundy drapes kept out the sun. As I took in the scene, so different from my recollection, my chest heaved and spasmed.

Such physical reactions and perceptions are common in acute grief. The death of a loved one is accompanied by waves of physical distress that can include muscle aches, shortness of breath, queasy stomach, and trouble sleeping. Food may have no taste, and some experience visual hallucinations. The grief-stricken may not believe their loved one is dead.

Grief in the time of COVID-19

Restrictions to help prevent the spread of COVID-19 disrupted social rituals that connect us during grief. In The Atlantic, Ed Yong describes this absence of much-needed support as the “final pandemic betrayal.”

Although my husband died of cancer, not COVID, I experienced the loss of comforting rituals and the sense that my grief was never truly acknowledged. Experts call this disenfranchised grief. Some predict that prolonged grief disorder driven by this pandemic may reach rates seen only in survivors of natural disasters and wars.

Grief is proof of love

Losing loved ones is not easily incorporated into our life story, though it becomes part of it. The finality and acceptance of a monumental loss takes time. In The Year of Magical Thinking, Joan Didion captures the sudden tragic death of her husband: “John was talking and then he wasn’t.” Life changes in an instant. Yet it takes time to untangle and embrace all that it means.

My life must now be reconfigured and re-envisioned without George. Letting go of grief happens haltingly. Gradually, I noticed that more of my memories of George were happy ones, slowly crowding out the all-consuming early intensity of grief. With time I began to re-engage with the world.

Just as George had, I found I wanted to talk with others in the same boat. A bereavement group helped. I began to exercise more. That helped too. When our dogs died, I got a new puppy. Above all, I learned to be kind to myself.

If you, too, are struggling with loss, experts advise some basics: try to eat, sleep, and exercise regularly; consider a bereavement group or seek out others experiencing grief; stay open to new possibilities — new hobbies, people, and opportunities. Talk to a professional if, after months, you are preoccupied with thoughts of your loved one or find no meaning in life without them. These may be signs that your grief is stalled or prolonged. Effective treatment can help.

Every “first” without George — the first birthday, first wedding anniversary, first anniversary of his death — awakened the early days of intense grief. Still, the experience of living through each made me realize I could survive. I think George would be pleased.

Additional resources

Grief and Loss, CDC

NIH News in Health: Coping with Grief, National Institutes of Health

The Center for Prolonged Grief, Columbia University

About the Author

Martha E. Shenton, PhD, Contributor

Dr. Martha Shenton is professor of psychiatry and radiology at Harvard Medical School, and director of the Psychiatry Neuroimaging Laboratory at Brigham and Women’s Hospital in Boston. She and her team have pioneered in developing neuroimaging … See Full Bio View all posts by Martha E. Shenton, PhD

I recently learned about a study suggesting a vegan diet is an effective treatment for rheumatoid arthritis.

While that sounded intriguing, another claim made in an interview about the study really caught my attention: the lead author of the study said that physicians should encourage people with rheumatoid arthritis to try changing their eating patterns before turning to medication.

Before turning to medication? Now wait just a minute. That flies in the face of decades of research convincingly demonstrating the importance of early medication treatment of rheumatoid arthritis to prevent permanent joint damage. An increasing number of effective treatments can do just that.

In fact, there’s no convincing evidence that changes in diet can prevent joint damage in rheumatoid arthritis. And that includes this new study.

So, what did this research find? Let’s take a look.

A vegan diet for rheumatoid arthritis

Researchers enrolled 44 people with rheumatoid arthritis in the study. All were women, mostly white and highly educated. They were randomly assigned to one of two groups for 16 weeks:

• Vegan diet. Participants followed a vegan diet for four weeks, followed by additional food restrictions that eliminated foods the researchers considered to be common arthritis trigger foods. These foods included gluten-containing grains (wheat, barley, and rye), white potatoes, sweet potatoes, chocolate, citrus fruits, nuts, onions, tomatoes, apples, bananas, coffee, alcohol, and table sugar. After week seven, these foods were reintroduced, one at a time. Any reintroduced food that seemed to cause pain or other symptoms of rheumatoid arthritis was eliminated for the rest of the 16-week period.
• Usual diet plus placebo. These participants followed their usual diet and took a placebo capsule each day for 16 weeks. The capsule contained insignificant doses of omega-3 fatty acids and vitamin E.

After the first 16 weeks, participants took four weeks off, then the groups swapped dietary assignments for an additional 16 weeks.

What did the study find about the vegan diet?

The vegan approach seemed to help lessen arthritis symptoms. Study participants reported improvement while on the vegan diet, but no improvement during the placebo phase.

For example, the average number of swollen joints fell from 7 to 3.3 in the vegan diet group, but actually increased (from 4.7 to 5) in the placebo group. In addition, while on the vegan diet, participants lost an average of 14 pounds, while those on the placebo gained nearly 2 pounds.

What else do we need to consider?

While the findings sound great, the study had significant limitations:

• Size. Only 44 study subjects enrolled and only 32 completed the study. With such small numbers, it only takes a few to alter the results. Larger studies (with several hundred or more participants) tend to be more reliable.
• Lack of diversity. This trial did not include men and had mostly white, highly educated participants.
• No standard diagnosis of rheumatoid arthritis. A physician’s diagnosis was required, but there was no requirement that standard criteria be met.
• Study duration. A treatment lasting four months may seem like a long time, but for a chronic disease like rheumatoid arthritis that can wax and wane on its own, this is too short a time to make firm conclusions.
• Self-reported diet. We don’t know how well study subjects stuck to their assigned diets.
• Medication use. Study subjects took arthritis medications, though no information on specific drugs is offered. Some made dosage adjustments during the trial. While the researchers tried to account for this through a separate analysis, the small number of participants could make that analysis unreliable.
• Weight loss. Losing weight, rather than eating a vegan diet, might have contributed to symptom improvement.
• No assessment of joint damage. No x-rays, MRI results, or other assessments of joint damage were provided. That’s important, because we know that people with arthritis can feel better even when joint damage continues to worsen. Steroids and ibuprofen are good examples of treatments that reduce symptoms of rheumatoid arthritis without protecting the joints. Without information about joint damage, it’s impossible to assess the true benefit or risk of relying on a vegan diet to treat rheumatoid arthritis.

Finally, it’s unclear how a vegan diet would improve rheumatoid arthritis. This raises the possibility that the findings won’t hold up.

Should everyone with rheumatoid arthritis become vegan?

No, there isn’t enough evidence to justify recommending a vegan diet — or any restrictive diet — for everyone with rheumatoid arthritis.

That said, a plant-rich diet is healthy for nearly everyone. As long your diet is nutritionally balanced and palatable to you, I see little harm in adopting an anti-inflammatory diet. But in the case of rheumatoid arthritis, diet should be combined with medicationto prevent joint damage, not used instead of it.

The bottom line

Growing evidence suggests diet can play a role in treating rheumatoid arthritis. But it’s one thing for a person to feel better on a particular diet; it’s quite another to say diet is enough by itself.

For high cholesterol or high blood pressure, dietary changes are the first choice of treatment. But rheumatoid arthritis is different. Disabling joint damage can occur early in the disease, so it’s important to start taking effective medications as soon as possible to prevent this.

We will undoubtedly see more research exploring the impact of diet on rheumatoid arthritis, other forms of arthritis, and other autoimmune disorders. Perhaps we’ll learn that a vegan diet is highly effective and can take the place of medications in some people. But we aren’t there yet.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD