swxc yom tov guide yom kippur w - friends with diabetes · swxc yom tov guide w elcome back to the...

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Y O M T O V G U I D E

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W elcome back to the big YomKippur dilemma. You probably are

not even aware of many of the lurking dan-gers inherent in a fast day, for both the type1 and type 2 diabetic. Although you mightfeel that you are familiar with the particu-lar affect insulin has on your body, and youthink that you are able to control it ifeverything goes according to plan, it can

still be a dangerous act. The Torah doesnot give us permission to put our bod-

ies in danger.

Just as we are required to buy a lulavbefore Succos and to prepare matzosbefore Pesach, so too, one with a medicalcondition is obligated to research andknow how to act on Yom Kippur. Onemust find out if s/he should fast and fulfillthe commandment of "ofh,apb ,t o,hbgu"-“and you shall inflict your soul,” or if thisis prohibited for him/her, and s/he mustrather fulfill the commandment of"ofh,apbk stn o,rnabu"-”and you shallguard your soul very much.”

As before every crucial decision, it’s impor-tant to know the risks of fasting if you havediabetes. Whatever you decide to do in theend, you’ll be sure to do it safely!

Our bodies - and our brains in particular -require a continuous supply of glucose forenergy. However, we don’t eat constantly,and we rarely eat pure glucose. We don’thave to; the Ribono Shel Olam hasequipped our bodies with the remarkableability to store energy for use betweenmeals.


WYom Kippur

to fast or not to fastHEN I WAS FRESHLY DIAGNOSED WITH DIABETES, AND STILL

INNOCENTLY UNAWARE OF WHAT IT WAS ALL ABOUT, MY

PEDIATRICIAN GAVE THE FOLLOWING ANALOGY: “LIVING

WITH DIABETES IS LIKE CROSSING THE STREET. THERE IS ALWAYS

A SMALL DANGER INVOLVED, BUT IF YOU’RE CAUTIOUS, YOU

WILL VERY LIKELY ARRIVE SAFELY AT THE OTHER SIDE.”

THIS SIMPLE COMPARISON REFERS TO A STANDARD DAY,

OF COURSE. THERE ARE ALSO TIMES LIKE SHABBOS AND THE

VARIOUS YOMIM TOVIM WHICH EACH PRESENT ADDITIONAL, DIS-

TINCT CHALLENGES TO MASTER SUCCESSFULLY. AND THEN

THERE’S FASTING ON YOM KIPPUR.

IMAGINE A BROAD, MULTI-LANE HIGHWAY. CARS AND TRUCKS

ARE WHIZZING PAST IN DIZZYING SUCCESSION AT 65 MPH.

FEELING FAINT, HEART PUMPING WILDLY, YOU CONSIDER REACH-

ING THE OTHER SIDE OF THIS HECTIC THOROUGHFARE. THERE IS NO

WAY, YOU KNOW, THAT YOU CAN CARELESSLY SKIP ACROSS; JUST ONE

FALSE MOVE CAN HAVE SICKENING CONSEQUENCES. EVEN EXERCISING

EVERY CAUTION WILL NOT BE QUITE ENOUGH. THERE IS NO DOUBT: THE

SITUATION YOU ARE FACING IS A DANGEROUS ONE AND A LACK OF

FORETHOUGHT SPELLS MOST CERTAIN DISASTER.

TIME IS NOT ON YOUR SIDE. EVERY TAUT BRAIN CELL

WEIGHS THE SPLIT-SECOND DECISION: TO GO OR NOT

TO GO? TO RISK OR NOT TO RISK?

The Risks:Fasting & Diabetes

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The Yom Kippur article is also available inYiddish upon request (printed in 5762).

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The carbohydrates we consume areconverted into glucose. The glucosethen travels through the blood streamand enters cells in need of energy withthe help of insulin. The cells willeither use the sugar for immediateenergy or store it as glycogen forfuture use.

During a fast, a healthy body will tryto keep blood glucose levels fromfalling too low by signaling cells torelease glycogen, which is then con-verted back into glucose, so the vitalorgans and the brain continuouslyreceive glucose for energy.

UnpredictableBlood Sugars

When a person with type 1 diabetesstops eating but continues takinghis/her basal or long acting insulin,blood sugar levels could remain in thenormal range. However, if the long-acting insulin dose is too large, lowblood glucose levels may result. If thedose is too small or no insulin istaken, glycogen stores will be convert-ed into glucose, and high blood glu-cose levels will result. That is why it isextremely difficult to keep blood sug-ars balanced during a fast! It’s likewalking a tight rope.

KetonesThe body’s glycogen stores are deplet-ed in less than a day. As fasting con-tinues beyond twenty hours, the bodywill have to create other energyreserves, so it will burn fatty acids inorder to get the necessary energy. Thisprocess of creating energy also gener-ates potentially harmful by-productscalled ketones.

For people with diabetes, high ketonelevels pose the grave danger ofketoacidosis, a life threatening condi-tion that requires prompt medicaltreatment. A buildup of ketones may

cause sweetish, acetone breath odor,dehydration, and potassium and sodi-um imbalances. (High potassium lev-els can impair nerve impulses andmuscle contractions that are necessaryto keep the heart pumping.)

Severe Low BloodGlucoseAs mentioned above, the body willnormally use stored glycogen to raisea low blood sugar. However, sinceglycogen stores deplete rapidly duringa fast, the body will not have enoughglycogen with which to adequatelyrespond to a low glucose level, andblood sugars may fall very severelyand dangerously. This is true for 24hours following the fast and may evenlast for several days after the actualfast! As the body is still attempting torebuild glycogen stores, a low bloodsugar can spell disaster ch”v.

If you experienced asevere low bloodsugar reaction dur-ing the day or twobefore Yom Kippur,fasting can pose aneven greater hazard,as your glycogenstores were alreadyexhausted due to thereaction.

Effects ofDehydrationDehydration presents some seriousconsequences for those with diabetes.Glucose concentrations in the bloodwill rise when dehydrated, as theblood lacks the liquid that normallydilutes it. Therefore, an elevatedblood sugar reading when dehydratedmay be misleading. Your body wouldreally be missing water, not necessari-ly insulin. Taking extra insulin canlead to an unexpected episode of

hypoglycemia, since the decision wasbased on a misleading blood glucosereading.

Also, dehydration decreases the bloodflow to subcutaneous tissues, imped-ing the absorption of insulin.

Remember that high blood sugarsduring a fast may accelerate theprocess of dehydration. And bloodsugar levels may be harder to bringdown if you are not ingesting liquids,which normally flush sugar out of thekidneys.

Worsening ofComplicationsIf you have complications fromuncontrolled diabetes or if your bloodsugar levels are out of the normalrange, don’t be surprised if your dia-betes-care provider recommends thatyou don’t fast; fasting could worsenyour health.

U ltimately, the determination ofwhether or not YOU may fast

on this year’s Yom Kippur will dependon your Rav, your doctor, and yourself.If any of these three feels that you maynot fast… then that is what you mustdo. (See “For those who will not befasting” later on in this article.)However, if you are granted the “greenlight”, then perhaps these guidelineswill help you prepare yourself adequate-ly so that you can safely and successful-ly reach your goal.

If you get the “Go Ahead”

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— A CHECKLIST

First, some vital basics: I am on flexible insulin therapy; either on an insulin pump or on multiple daily injections (MDI). My

basal rate or long-acting insulin covers only my basal needs and not food. (Psst… If you are not yet

on this regimen, it may be time to realize that only this type of therapy allows for a truly flexible

lifestyle. The insulin pump is the preferred tool for anyone who is attempting to fast on Yom Kippur.)

My long-acting or basal doses have been rechecked recently, to insure that they do not allow

blood sugar swings.

(This is done by skipping a meal and checking every two hours until the next meal to insure that

blood sugars remain in range. Basals are checked over the course of a few days, skipping only

one meal daily and drinking plenty of water. For detailed instructions you can refer to Pumping

Insulin, page 97. Your diabetes educator can help you too and may have some ready-made charts

and instructions for the basal check.

Note: The days when arising earlier for Slichos may be an ideal time for basal checking.)

My blood sugar control has been good, and my readings are basically in range. (If your control

has been erratic, we strongly discourage fasting. You may be one of those few people who,

despite every effort, have a harder time getting a good handle on those blood sugars.)

I have permission to fast from both my Rav (who understands diabetes) and my doctor.

I am well prepared: I have discussed with my doctor for this year’s Yom Kippur:

At what value will my blood sugars be too low, & obligate me to treat, stay home, & monitor?

When will my blood glucose be considered too high, & compel me to treat & follow up at home?

I have reviewed with my Rav all halachos that are or may be applicable.

I am fully prepared by knowing the shiurim (allowed amounts) for eating and drinking. I’ve

alsoprepared small cups to drink in, if needed.

I have prepared in Shul:

A meter Food (i.e. Winkies, Rockets, juice) Unexpired Glucagon

I hereby undertake: If my sugars fall below the number indicated by my physician, I will IMMEDIATELY consume

some glucose, without waiting an extra moment.

If my blood sugar is high and ketones are present, I will drink lots of fluids (NOT pachos m’k-

shiur), as specified later on.

I will stay home if my blood sugars are out of range (as directed by my doctor) and keep on

checking until they return to normal.


Aare you a FASTING CANDIDATE?— A CHECKLIST

First, some vital basics: I am on flexible insulin therapy; either on an insulin pump or on multiple daily injections (MDI). My

basal rate or long-acting insulin covers only my basal needs and not food. (Psst… If you are not yet

on this regimen, it may be time to realize that only this type of therapy allows for a truly flexible

lifestyle. The insulin pump is the preferred tool for anyone who is attempting to fast on Yom Kippur.)

My long-acting or basal doses have been rechecked recently, to insure that they do not allow

blood sugar swings.

(This is done by skipping a meal and checking every two hours until the next meal to insure that

blood sugars remain in range. Basals are checked over the course of a few days, skipping only

one meal daily and drinking plenty of water. For detailed instructions see the end of this article.

Your diabetes educator can help you too and may have some ready-made charts and instructions

for the basal check.

Note: The days when arising earlier for Slichos may be an ideal time for basal checking.)

My blood sugar control has been good, and my readings are basically in range. (If your control

has been erratic, we strongly discourage fasting. You may be one of those few people who,

despite every effort, have a harder time getting a good handle on those blood sugars.)

I have permission to fast from both my Rav (who understands diabetes) and my doctor.

I am well prepared: I have discussed with my doctor for this year’s Yom Kippur:

At what value will my blood sugars be too low, & obligate me to treat, stay home, & monitor?

When will my blood glucose be considered too high, & compel me to treat & follow up at home?

I have reviewed with my Rav all halachos that are or may be applicable.

I am fully prepared by knowing the shiurim (allowed amounts) for eating and drinking. I’ve also

prepared small cups to drink in, if needed.

I have prepared in Shul:

A meter Food (i.e. Winkies, Rockets, juice) Unexpired Glucagon

I hereby undertake: If my sugars fall below the number indicated by my physician, I will IMMEDIATELY consume

some glucose, without waiting an extra moment.

If my blood sugar is high and ketones are present, I will drink lots of fluids (NOT pachos m’kshi-

ur), as specified later on.

I will stay home if my blood sugars are out of range (as directed by my doctor) and keep on

checking until they return to normal.

I am ready to check my sugars at least every two hours, and more if needed.


Erev (eve of) Yom Kippur:

For the last two meals, eat and coverwith insulin accordingly, as usual. Asthe meals are in close proximity of

each other, use the unused bolus/insulinrule when taking insulin for the secondmeal. (See Pumping Insulin, chapter 13)In order to avoid dehydration on YomKippur, it is recommended to drink atleast 10 glasses of water throughout thepreceding day. Although the mitzvah todrink on Erev Yom Kippur is only amelo lugmav (less than 2 oz), one whois going to fast should make sure todrink 8-10 glasses of water.There are those who recommend eat-

ing large amounts of carbohydratesbefore a fast day. Keep in mind that

this will also necessitate takingmore insulin and possibly goinglow, so stick to normalamounts. Also remember thatif you overdo the carbs youmay be increasing yourchance of high blood sug-

ars, which will cause more thirst anddiscomfort throughout the fast.Many people believe they need to eatalmost non-stop on Erev Yom Kippurin order to fulfill the obligation of eat-ing on that day. But in truth, the accept-ed ruling of the Minchas Chinuch isthat one must eat a K’kosvos of food.For example, just one fifth of a bagel(25 grams in weight) would already suf-fice for that amount! (Some rule thateating even less than this measurement

is also adequate.)Other poskim state that in order to ful-fill the mitzvah one should eat slightlymore than the amount eaten on a usualday. It is also possible to accomplish themitzvah and avoid high blood sugars byeating foods (i.e. proteins and vegeta-bles) that have a minimal effect onblood sugar levels.There is no need to eat more than therequired amounts, and in fact, overeating

Your doctor has a very crucial inputon whether you may or may not faston Yom Kippur. Remember, however,that his job is only to state definitive-ly whether it is medically permissiblefor a person to attempt to fast. Hedoes not have the power to give opin-ions such as, “You can try to take thechance”, or “Since it is so importantto you, I think you can risk it…” Only ifhe grants his full permission for youto fast, may you do so on Yom Kippur.Otherwise, the Torah has alreadymade the decision: You are notallowed to fast.

Perhaps an explanation from theSteipler Goan zt”l would be helpful.

When a person who was very close tothis tzadik had a sick relative, the Ravtold him to clarify with the patient’sdoctor how he defined “pikuachnefesh”. Some doctors identifypikuach nefesh as a state of presentand immediate danger, he explained,however, this definition is incorrect.

They have to understand that pikuachnefesh refers to a situation in whichthere is the slightest chance that evenone person out of a thousand wouldencounter danger, even many yearsdown the line!

A person who suffered from a healthcondition once approached theBrisker Rav, repeating his doctor’sdeclaration that it would actually bebeneficial for him to fast on YomKippur. The Brisker Rav retorted, “OnYom Kippur, I will not permit you tofast. However, since the doctor said itwould be advantageous for you tofast, I will allow you to do so the dayAFTER Yom Kippur!”

R’ Menachem M. Weismandel,shlit”a, of Nitra, Monsey, repeated astory about his Rebbe, R’ Yashu BerSoloveitchik, zt”l, who suffered from aheart problem. During the month ofAv, he consulted a Jewish doctor andasked him if he would be permitted tofast the next day. The doctor replied,


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Gguidelines forFasting on Yom Kippur

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is forbidden (achila gassah). One whoovereats has not fulfilled the mitzvah.

The Fast Day:Checking Blood Sugars:

Imagine, for a moment, that you startadvancing across that dangerous high-way crowded with speeding vehicles.

Suddenly feeling tired, you allow youreyelids to droop. A lumbering truck isadvancing, bearing straight towardsyou, but your eyes are closed; you’reunaware…If you’re shuddering in fright just read-

ing the analogy, then remember this:Failing to perform frequent blood

sugar checks while fasting is likecrossing a dangerous road witheyes closed. Our recommenda-tion is to test every two hours,and whenever you are unsureof your blood sugars based onhow you feel.Checking blood glucose onYom Kippur is done the same

way you do it on Shabbos (i.e. with ashinui). You are allowed to check asoften as needed.Even those who eat pachos m’kshiurmust check their blood sugars moreoften, because the food consumptiondiffers greatly from that of a usual day.Don’t forget to record your fastingbasals and blood sugars! These willcome in very handy when Yom Kippurrolls around next year… unless we arealready in Yerushalayim, iy”h.

Davening in Shul:According to Rav Weissmandl shlit”a, ifone finds it hard to daven in shul with aminyan while fasting; he should ratherdaven at home and not compromise hisability to fast.

Blood Glucose Target:It is advisable to target for slightly high-er blood glucose values, in order to beon the safe side. Some have found thatit is preferable to stay in the 130-150mg/dl range to avoid a low blood sugar.Remember that, as we already men-

tioned, when the body is dehydratedyou may get false higher readings, so itpays to lower basal insulin somewhat.While fasting, the body and the insulincan respond unexpectedly.

High Blood Sugar:If your blood sugar goes above thenumber you and your doctor agreedupon (perhaps about 240 mg/dl), it isadvisable to check for ketones. Dr. DonZwickler has offered the followingguidelines: If the ketones are small, thenjust ignore them and take care of yoursugars. If they are moderate, it is a sofekpikuch nefesh, and one should drinkpachos m’kshiur. (Even though theketones may result only from starvation,they can also be caused by a lack ofinsulin.) If the ketones are large, onemust drink enough fluids to wash themout of the body systems. It is vital atthat point to stay home and keep check-ing until blood sugars go down.All insulin corrections should be madecautiously. If you are on the pump, cor-rect carefully in tenth-unit increments,while those on injections can use half or

“Tomorrow I do not allow it,but on the holy day of YomKippur you will be ablefast.” R’ Yashu Ber said, “If Iam not permitted to fasttomorrow, then I am notpermitted to fast at all.Obviously, you are permit-ting me to fast on YomKippur only because of itsextreme sanctity. But this

decision is not in yourhands; itcan only bemade by aquali f iedr a b b i . ”And therebbe didnot fast!

An inter-esting minhag

(custom) wasp r a c t i c e d

in the city of Pressburg. On YomKippur, the people of this town wouldcall a doctor up to the Torah, and theywould title him “morainu”, a designa-tion usually reserved for rabbinicalauthorities. They did this because ofthe halacha which states that apatient must be fed on Yom Kippuraccording to doctors’ orders. On thisholy day, the Torah gave doctors thepower to decide how people shouldact. Therefore, it is fitting to call themby this revered title.

One of our members shared the fol-lowing, frightening story: An ill per-son was advised not to fast on YomKippur, by both his doctor and thevenerable Rav Yaakov Kaminetsky. Hechose to fast anyway, thereby caus-ing his condition to deteriorate until it led to his death. Rav Yaakov then refused to eulogize thedeceased, stating that he had com-mitted suicide.

The Sefer Hadras Kodesh contains anaccount of the last Yom Kippur in thelife of the holy R’ Yisrael of Sadigora.During the fast, this tzadik said thathe was experiencing a strong thirstfor water. Unfortunately, no one toldhim to take a drink. He later said thathad someone told him to drink, hewould have done so. He was niftarthat year, in the next month ofMarCheshvan. May his memoryguard us.

The tzadik R’ Yehoshuah of Belz zt”l,wrote a letter to the holy Rav, R’Mendel of Viznitz zt”l, the TzemachTzadik, as follows:

“I am very surprised to hear that ourcompatriots are afraid that your holi-ness will want to fast on the soon-to-be-celebrated, sacred day of YomKippur. I cannot believe this of a holyman like yourself, may such multiplyin our nation. Isn’t it true that thesame Shepherd who said not to eat


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even third-units. Remember thatRegular insulin lasts in the body for 4-6hours, and Humalog remains active for3-4 hours. Be very cautious when apply-ing the unused insulin rule.

Low Blood Sugar:Any blood glucose reading below thenumber you and your doctor agreedupon (probably about 70 mg/dl) shouldbe treated. Afterwards, stay home andkeep testing every 15 minutes until yoursugars come back up. One package ofWinkies or Rockets will raise blood sug-ars approximately 38, 30, or 23 mg/dl,if you weigh 100, 150, or 200 pounds

respectively. This varies with eachindividual and with different levels

of activity, so test it out. (OneWinkie roll contains 7.6 grams ofglucose.)

If the low blood sugar occurs whileinsulin is peaking, it may be necessary toeat something in addition to the Winkies(preferably something containing fat orprotein, such as peanut butter, to keepsugars leveled), but eat the Winkies first.(This should rarely happen, as thosewho are not on the insulin pump areadvised to fast only if their long-actinginsulin has a nearly consistent andsmooth action throughout the day.)For Friends and Family: Glucagon shotswork by signaling the liver to release itsstored glycogen. Since this store isdepleted while fasting, there have beenconcerns expressed about whetherGlucagon would be of value for some-one who has a severe low while fasting.The doctors we consulted (Dr. D.Zwickler and Dr. D. L. Raice) felt thatthe extra food eaten on Erev YomKippur, plus the fact that glycogenstores become completely depleted only

after 48-72 hours of starvation, indicatethat Glucagon should work on YomKippur. Hopefully, those who fast will takeenough precautions to ensure that thiscatastrophic state is not reached.However, those who will be with thediabetic during the fast day shouldknow how to administer Glucagon andof the necessity to call Hatzalah or EMSin case there are no results after theinjection.

Basal or Long-acting insulin:A pumper who has correct basal rates(checked before Yom Kippur) shouldnot need to change them much. Asmentioned above, it is advisable toreduce them a bit and aim for slightlyhigher blood sugars during the fast,especially if this is the first time you arefasting. Some people do need a some-

on Yom Kippur also com-manded that, in an instanceof need, “and you shallguard your health”? Iremember that when myfather (the tzadik R’ Sholomof Belz, zt”l) was ill, we werein a quandary lest he wouldrefuse to eat on Yom Kippur.As it turned out, due to hisgreat tzidkus, he fulfilledhis obligation with alacrity.Immediately after KolNidray he hurried to com-mand us to give him food aswas necessary. He then said

these words: “I am aboutto fulfill the

‘mitzvah ofour cre-ator’ asw a st a u g h t

by ourc h a z a l , ”

after whichhe ate withsuch great

joy; wehad hard-

ly seen him as happy except when heate matzah and when he shook thelulav… Surely, your holiness will beequally meticulous in fulfilling thismitzvah, and you will behave as yourdoctors have advised. Especially asyou are a respected individual whommany Jews strive to emulate, it isimportant that you are very careful.If you will be excessively stringentwith yourself, then others will learnfrom you and ch”v act dangerously as well.”

(Note: One may well wonder why RavShalom experienced such extreme joywhen eating on Yom Kippur. Theanswer is simple: other mitzvahs arean obligation on all Jews equally, buteating on Yom Kippur to preserveone’s health is a mitzvah that only aselect few merit to fulfill. This is whythe tzadik was so ecstatic; he hadmerited fulfilling this special mitzvahcompletely and with happiness.)

In a similar vein, Rav Segal zt”l,famed Manchester Rosh Yeshiva,took ill one Shabbos and was taken tothe hospital by ambulance. While hewas entering the ambulance, he

noticed that his daughters were cry-ing, expressing their deep pain thattheir revered father was forced to bemechalel Shabbos. Undisturbed, theRosh Yeshiva explained, “Today, thisis my mitzvah, so we must be happy”.

The Midrash relates that the tenth ofTishrei- Yom Kippur- coincided withthe chanukas habayis celebration ofthe first Bais Hamikdash. At that par-ticular time, the Sages ruled that KlalYisroel should not fast, as this woulddetract from the joy of the occasion.Although this ruling was obeyed,many Jews remained uneasy abouteating on this holy day. A bas kol thenannounced that there was no need toworry, as the nation’s eating on thatday was accepted as if they had fast-ed. A meal which is eaten in kedushaand holiness is more beloved by theribono shel olam than a day of fasting.

May all who have the mitzvah of eat-ing on Yom Kippur do so with elation,with pure and holy intent. The properfulfillment of their obligations willsurely be beloved and precious forthe ribono shel olam!


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Y O M T O V G U I D EY O M T O V G U I D E

Serving Hashem with Joy— A TEF ILLA —

“I am about to fulfillthe mitzvah of eating and drinkingon Yom Kippur as it is stated inyour Torah, ‘And you shall guardmy statutes and my laws which aperson should fulfill so that he willlive’ (Vayikra 18:5). In the merit ofthis mitzvah, may you bless me andall the ill of your nation, Yisrael, witha complete recovery. And may I meritthat next Yom Kippur I should be ableto fulfill the commandment of ‘and youshall distress your souls.’ Amein, may itso be your will.”

(Sefer Nitei Gavriel, quoted from an ancient machzor)

‰zevnŠ miiwl onefne oken ippdŠmixetkd meia dizye dlik` ,jzxeza zazky enk ihtyn zè izeweg z` zxnye.mda ige mc`d mze` dyri xy` (‡d gŠi `xwie)

ize` mezgz ,ef devnd meiw zekfae,l`xyi jnr ileg lk zè

,dnily dètxlaey miiwl àd mixetkd meia dkfèmkizeytp z` mzipre

.Šon` oevx idi ok

Aperson who must eat on Yom Kippur isnot permitted to take stringencies uponhimself by refraining from eating. Do

not feel distressed about this, because byeating on this holy day, you will be ful-

filling Hashem’s commandments of“and you shall live by them” and “you

shall guard your health to theutmost”. The mitzvah of “V’chai

bahem”- and you shall LIVE by them, isthe most chashuv mitzvah and overridesalmost any of the other 613 mitzvahs. TheShach (Y”D 238:5) points out that everyperson has already sworn at Mount Sinai,when he accepted all the mitzvahs, that hewill also keep the mitzvah of saving hislife.

The Rishonim comment that onewho is overly strict with him-self against medical advicewill be held to blame for any

mishap, as the Torah says: “Hashem willdemand a strict accounting of such a per-son for the blood of his soul”. Fastingagainst medical or rabbinical advice is notan act of piety but one of shedding blood(Ran and Radvaz). In fact, the poskimargue whether this would be considered amitzvah stemming from sin (MahariAsad), or if there is no mitzvah involved atall, only a transgression (Maharam Shick,Minchas Yitzchak)!In addition, an accounting will ultimatelybe given not only for the harm the personcaused for himself, but also for the harmhe caused those who imitated his negativeexample. “It behooves him to guard him-self from such a great sin on such an awe-some day,” warns Rabbi Akiva Eiger.It is interesting to note that there are threepsukim that mention the phrase “yoursoul”: “And you shall oppress your soul,”

For thosewho will notbe Fasting

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what lower basal later in the afternoonduring a fast day, so it would be wise tobe cautious and set your basals to beslightly decreased at that time.

If you are on multiple injections, night-time long-acting insulin should be takenat bedtime in the usual amount. It iseasy to forget, so make yourself areminder to take your insulin afterreturning from Shul at night. For thosewho have a bedtime snack, discussreduction adjustments with your doc-tor. However, as your long-actinginsulin obviously covers food besidesbasal needs, we strongly discourage youfrom fasting.

Morning long-acting insulin which isprecise for basal needs only, should nothave to be decreased while fasting.However, some people do find thattheir long-acting needs to be loweredanyways. (If it covers lunch and snacks,which are eliminated on Yom Kippur,then a larger reduction is called for. Westrongly discourage those on this regi-men from fasting). It is preferable to stayon the side of caution and take a little bitless, and if needed, correct in the after-noon with the usual correction ratio.

In general, those taking Lente orLantus, as opposed to NPH, will havean easier time fasting, since they usuallyhave a milder peak. Discuss this withyour doctor.

Note for Pumpers:Pumps have an “auto off ” feature,which will turn off the pump andprompt an alarm if no buttons werepressed in a predetermined amount oftime. Since there is a good chance thatyou won’t need to press any buttons onthe pump throughout Yom Kippur,make sure to disable that feature inadvance. This way, you will not beforced to stop the alarm on YomKippur, and you will also be spared theuncomfortable situation of having yourpump alarm go off in Shul. (If you areon the Disetronic H-Tron pump, beaware that this feature can only beturned off by a trainer who has a con-

nection port).


Your doctor, who knows your per-sonal regimen and history ofdiabetes control, has to address

this question, but here are somebasics: If your pills are from theclass of drugs that stimulate thepancreas to produce more insulin,then there would be a definite needfor a customized decrease orcomplete elimination ofthe meds. This is thesame as for a persononinsulin,whowillneed todecreaseinsulindosagewhenfastingbecausetherewill beno foodfor the insulin to work on. Thiswould also apply for those who takedrugs that slow the absorption offood intake, as there is, of course,no food to be slowed on YomKippur. But not all drugs have thistype of action; some work on sensi-tizing liver cells and muscle cells toinsulin, and their dosages may notneed to be decreased.

Those who are advised to fast but tocontinue taking their medications,have the option of dissolving a tinyamount of the pills in water beforeYom Kippur. The water can then be

considered a part of the medication,and this is therefore the preferredmethod quoted in Sefer ShabbosShabbason. Discuss with a medicalprofessional if this would ruin theeffect of the medication, but remem-ber also that some pills will not workeffectively when taken without

water, and they may also causeirritation if swallowed

without a liquid.

Dr.Zwickler

cautions asto the

importanceof being

attentiveto the

specificdetails ofthe med-

ication youare taking.

It may befine to dissolve regular Glucophage

pills in water, but the extendedrelease tablets such as Glucophage

XR or Glucotrol XL will lose theirefficiency when dissolved in liquid.

So again, talk about it with yourdoctor! This would also be a goodopportunity to inquire about thetype of drug you are taking, itsaction, and side effects (low bloodsugars etc.). Ask your doctor, “Whyam I taking these particular med-ications?” Of course, you care aboutanything that goes into your bodyand you want to know what it does!

?Should you takeyour oral medications

while fasting

“And you shall guard your soul,”“Hashem will demand a strictaccounting of such a person for theblood of his soul,” which indicatesthat these three topics are related.It is helpful to bear in mind whileeating on Yom Kippur that you areeating at that moment not for “plea-

sure”, but merely for “sustenance”.The yetzer harah may do his utmostto prevent you from expressing joyand ecstasy at your ability to performthis most precious and importantcommandment on the holiest day ofthe year. But don’t let yourself befooled!


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Note: Before the fast day begins, weare required to learn the hala-chos of EATING on this holyday. Even one who is planningto fast on Yom Kippur must befamiliar with the following hala-chos, just in case.

If eating is needed, one should, if pos-sible, eat pachos m’kshiur- less thanthe minimum amount that consti-tutes “eating” according to halacha.As four Winkie rolls are still less thanthe shiur, one should normally notneed to exceed this amount. The shiurfor eating is 25-30 cc of a food item.A small, one-ounce “schnapps cup”holds about that amount, and anyfood that fits into that size cup istherefore permissible. However, doremember to measure the cup you willbe using before Yom Kippur, as someof them hold more than one ounce.

Your doctor will probably tell youthat drinking is even more importantthan eating, in order to avoid dehy-dration. At one time, drinking isallowed up to the amount of melolugmav, which averages about 40 cc(1.35 ounces) in an adult. Melo lug-mav literally means the amount of liq-uid which fills one check. If one fillsone’s entire mouth as much as possi-ble; half this quantity is certainly lessthan a melo lugmav.

If ketones and blood sugars are high,there is no shiur for drinking.

According to some poskim, thosewho will be eating and drinking

pachos m’k-shiur shouldprepare thefood in small,precise por-tions beforethe fast daybegins. Thereare specialcups availabletoday that arep r e m a r k e d

with all the shiurim and might comein handy.

Waiting Time:

One has to wait between eating ses-sions preferably 9 minutes. (Some say

this number refers to the time elapsedbetween the end of the first eatingand the beginning of the second.) If itis urgent, (beshas had’chak) one mayeat after 7, 5, or even 4 minutes.

Between drinking sessions, oneshould wait preferably 5 minutes. Ifurgent, it can be up to a half a minuteapart.

At one time, a person may eat theallowed amount, and he may drink theallowed amount at the same sitting.

Other Halachos:

The general halacha is that on foodswhich have the same bracha, one


Some Suggestions of foods that are

Pachos M’kshiurFrom Rav Weissmandl shlit”a

• 2 Jack and Jill cookies/ Tea Biscuits.

• 1/6 of an apple• 1/3 of a machine Matzah

• 1/2 of a chicken drumstick

• the amount of cottage cheese that fills a

shnopps cup• 4 Snackers or Saltines

• 2/3 slice American cheese.

• 6 Tam Tam Snackers

• 1 oz. of Yogurt

• [Interesting note: There is an argument between the poskim whether

yogurt and leben are considered food or drink items.]

• To keep a “balanced diet”, you may consider consuming a carbohydrate

during one eating session and a protein at the next.

• Sefer Shabbos Shabbason states that one may add 20 spoonfuls of sugar

to a cup of water, if this drink would normally be nauseating. If your

blood sugar is low and you do need a sweet drink, this would seem to be

the preferred choice.

Aamounts forPachos M’kshiur




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You may besurprised to hear

that almost everyone;diabetic or non-diabet-ic, experiences raisedblood sugars and itsuncomfortable symp-

toms to some extentafter breaking a fast.

Overdoing the carbohy-drates, even if they are ade-

quately covered with insulin, simplywill not work when the body is notready to handle such a heavy load. Thetrick is to eat light, low-carbohydratefoods, not to overeat, and to drinkplenty of liquids. If you eat over anextended period of time, the blood sug-ars will also be much less erratic. (Passthese tips on to your family members aswell! Everyone will benefit!)

BEWARE OF LOWBLOOD SUGARS:

The dangers of fasting do not disap-

pear with your first bite of food. Wealready mentioned that glycogenstores in the body are exhausted dur-ing a fast and may require up to a fewdays to replenish completely. Duringthat time, the body will not have themeans to raise a low blood sugar.Recall also that a Glucagon injectionmay not be as effective in the case ofglycogen depletion, so it is vital tosteer clear from lows until the bodyhas had a chance to renew its sourcesof stored glycogen. Aim for well-con-trolled, middle-range numbers, andbe especially wary of nighttime lows(nocturnal hypoglycemia) whichoccur in that dangerous zone whenyour body is naturally sensitive toinsulin, but you may be unaware ofthe warning signs.

FASTING ON DAYS BESIDESYOM KIPPUR:

This article should be used in refer-ence to Yom Kippur only. It is

absolutely not permissible, accordingto halacha, for those with type 1 dia-betes to fast at any other timethroughout the year! Remember thatit is only regarding Yom Kippur thatthe Torah allows a medical profession-al to decide if an individual is capableof fasting. This option is not given forany other fast day, when our poskimhave already concluded for us:Regardless of your level of bloodsugar control, fasting is forbidden.(Those with type 2 diabetes shouldconsult their Rav and doctor as indi-vidual cases may differ.)

We already mentioned numerous rea-sons why even a well-controlled dia-betic who feels s/he knows what todo, faces danger during a fast. Hereare two more points to think about:The stress your body undergoes whenstarving may, in and of itself, impactblood sugars. And the fact that somepeople need less basal insulin on a fastday, although their basal rates do notcover food, indicates that fastingdepletes glycogen stores.

“My doctor wants me to test my basalrates anyway” is not an excuse for fast-ing a full day. When fasting to checkbasal rates, one skips only a singlemeal. By no means does this compare


blessing suffices for all foods eatenwithin 72 minutes of each other. Butif the person intended not to eat fur-ther within that amount of time andlater changed his mind (i.e. there washesach daas), then a new bracha isrequired.

A brachah acharonah can be made ifthe food eaten amounted to a k’zayisand was consumed, preferably, withina time span of 9 minutes. However,b’dieved, it may be made even if thek’zayis was eaten over a greater periodof time. If an al hamichya is said (aftereating foods with the brachah ofmezonos), one should remember toadd the words, "ouhc vcuyk ubrfz

vzv ohrupfv"- “zochrainu l’tovah b’yom

hakippurim hazeh”.

If one will be eating bread, lechemmishneh is not needed. Washinghands prior to eating is required, asalways. The accepted psak is to washjust the fingers, as is otherwiseallowed on Yom Kippur, althoughsome poskim rule that the entire handshould be washed as usual. The bless-ing of al netilas yadayim is made. Onehas to wash mayim achronim, andyaaleh v’yavo will need to be said.

Kiddush does not have to be made.Even in the event that Yom Kippurfalls on a Shabbos, there is an argu-ment among the poskim whether ornot Kiddush should be recited. The

Mishneh Berurah concludes thatKiddush should not be recited, on thepossibility that it would be considereda bracha l’vatalah and the name ofHashem would have been said in vainch”v. However, one should recite thebracha of magen avos on Friday nightwith the specific intention of fulfillingthe obligation of Kiddush. Therefore,a woman who will not be fastingshould also make sure to daven marivon such a day.

There are numerous details involvedin fasting, many of which are beyondthe scope of this newsletter. Pleasetake some time to learn them and dis-cuss them with your Rav.

After the fast

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to an entire day of fasting. In addi-tion, you will not be drinking anyliquids while fasting (as opposed towhen you simply check basals), andthis can alter your blood sugars fromthose of a typical day.

YOU CANNOT play games withhalacha! Fasting is prohibited for adiabetic on any tanaisim other thanYom Kippur, and even then, it is

only allowed with the explicitpermission of your Rav and doctor,and with the proper precautions!

SOURCES

These are some of the Halachicsources we used, which can bereferred to for more information:

• Sefer Shabbos Shabbason, byRabbi Y. Zilberstien (the son-in-law of Rav Eliashiv shlit”a)

• Sefer Nitei Gavriel on YomHakippurim

• Sefer Nishmat Avraham, which isavailable in English.

• Sefer Halachos of K’zayis containsphotos of many food items in 28.8cc portions, approximately theamount of pachos m’kshiur.Many examples in this article aretaken from here.

T he Veitzenerefits.

RHMT he Veitzener Rav, my grandfa-

ther Reb Herschel Meisels zt”l,would drink chamomile tea or otherbitter teas on Yom Kippur withoutadding sugar. An even better optionwould be to prepare water cookedwith bitter herbs.

Rav Yitzchak Zilberstien Shli”ta, (inhis Sefer Shabbos Shabbason)brings an option from his brother-in-law, Rabbi Chaim Kanyevski Shlit”a,to prepare “ash” before Yom Kippurand mix this into the water. He alsoquotes the advice of the Steipler zt”lto cook water together with the peelof a pomegranate-Rimon. We knowthat eating this fruit is a good simanfor Rosh Hashanah, but it seems thatit is good for Yom Kippur too. He

goes so far as torecord in thename of a doctor

that it containssome health bene-

fits.

RHM

BEEWARE! InConclusion

DR. DON ZWICKLERENDOCRINE ASSOCIATES OF ROCKLAND

“It is a unique blessing that our community has agreat man who has the wisdom and compassion tocompose a Yom Kippur “how to” newsletter for dia-betics. Rabbi Hirsch Meisels, a special individual,has taken his precious time and valuable experienceas a diabetic himself, to develop an excellent guidefor the management of diabetes on Yom Kippur. Ihave reviewed his article and found it to be full ofuseful advice and lifesaving techniquesfor handling Yom Kippur,especially for those diabeticswho would like to fast. Hiskeen sense reminds thereader that no actionshould be taken withoutconsulting a personal physi-cian. Rabbi Meisels shouldbe zocheh to many blessingsfor his effort”

Don Zwickler

DR. HENRY ANHALTDIRECTOR, PEDIATRIC ENDOCRINOLGY

INFANT & CHILDREN’S HOSPITAL OF BROOKLYN MAIMONIDES MEDICAL CENTER

“Shalom Uvracha. I am pleased to offer my supportfor this very important work put together by RabbiMeisels. Clearly, for a person with diabetes, fasting isno simple issue, medically or halachically. Thisnewsletter lays the foundation for doctors and poskimto approach our fast days with even greater clarity

than existed before. Of exceptionalnote is the fact that RabbiMeisels stresses that fasting fora person with diabetes is not an

automatic yes and one must be sureto receive appropriate medical and

halachic dispensation in order to do so.Yasher Koach to Rabbi Meisels and best wishes

for all!”Henry Anhalt

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Dear Rabbi Hirsch Meisels,Congratulations on putting together such a useful and factual newsletter concerning Yom Kippur

and fasting with diabetes. Your advice was excellent and balanced. I might offer some comments insupport of what you wrote.

Type 1 diabetes: There is no doubt that the insulin pump provides true flexibility to deal best withsituations like fasting. As such, virtually all persons on insulin pumps can safely fast with their fami-lies. Since there are no carbohydrates consumed during the fast, there are no boluses taken for this pur-pose until the fast is over. Correction boluses are usually not needed either during the fast, and if givenshould be administered with care (not for a blood sugar less than 200, and at half the usual rates forglucose values above this level.) Since basal insulin is infused throughout, ketonemia is actually pre-vented more than would be the case for a non-diabetic person. We advise a reduction in the basal rateof about 20% over the fast period, and monitoring of blood glucose levels to learn how the body isresponding. These are general guidelines only, and your particular blood glucose information is usefulfor planning for the next fasting period.

For those on multi-dose insulin injections (MDI), Lantus is the safest long acting insulin available.Again, doses before the fast should be reduced by 20% and full doses resumed afterwards, with bloodglucose monitoring throughout the fast to ensure that the levels are satisfactory. Virtually all of ourpatients on MDI take one or two daily doses of Lantus and Humalog as needed (like for pumppatients). Patients on NPH, as you correctly point out, have a problem with fasting since that insulinhas a sharp peak at 6-8 hours that can induce hypoglycemia during fasting. For this reason, none of ourpatients who are still taking NPH (and very few are) are encouraged to fast.

Type 2 diabetes: Patients with type 2 diabetes usually do very well with fasting. Those on insulinsensitizers/gluconeogenesis inhibitors like metformin (Glucophage) and rosiglitazone (Avandia) shouldhave few problems with low blood glucose levels. We advise them to take their medications as usual.Patients on insulin stimulators like sulphonylureas, such as glyburide (Glucotrol) or repaglinide(Prandin) are at distinct risk of provoking an insulin level that is inappropriate for the fast andthus hypoglycemia. We advise that they be stopped during the fast period but taken theday before.

Gestational diabetes: Whereas we do not encourage fasting bythese patients, those treated by diet and exercisealone can fast safely. For those on multi-doseLantus and Humalog insulin or the insulin pump,we advise against fasting, albeit if patients followinstructions as above under type 1 diabetes, theyshould experience few problems in practice.

Thank you again for sending yourimportant newsletter. The practical andaccurate information in it should be help-ful to the whole diabetes community wish-ing to take part in Yom Kippur.

Kind regards,Noel K Maclaren MDDirector and Profesor, Diabetes ProgramNY Cornell University



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Ffine-tuningBasal Rates

Basal insulin controls your blood glucose overnight and betweenmeals. It is the small, continuous amount of insulin delivered every 3minutes by your insulin pump. The goal is to set basal rates that willhelp keep your blood glucose stable without the need for extra food orinsulin. Most people begin with just one basal rate per day. Soon afterstarting pump therapy, your basal insulin will need to be fine-tuned,and other basal rates (segments) will likely need to be added, to obtainoptimal blood glucose control. To evaluate your basal rates, you willneed to check blood glucose levels frequently while eliminating otherfactors that may affect blood glucose.

B A S E L R A T E S

TIME FRAMESAND DIRECTIONS

OVERNIGHT:- Eat an early dinner-Don’t forget your meal bolus- No food afterwards- Begin evaluation at bedtime

BREAKFAST-TIME:- Skip breakfast- No food until lunch- Begin evaluation if BG is

between 100-150 mg/dl

LUNCH-TIME:- Skip lunch- No food until dinner- Begin evaluation if BG is

between 100-150 mg/dl

DINNER-TIME:- Skip dinner- Begin evaluation if BG is

between 100-150 mg/dl- Have a bedtime snack, and

end the evaluation then ifdesired

WHEN TO TESTBLOOD GLUCOSE

4 hours after dinner bolus Bedtime Midnight 2-3 am Upon waking

Every 1-2 hours upon wak-ing until lunch

4 hours after breakfast Every 1-2 hours until dinner

4 hours after lunch Every 1-2 hours until dinner

or snack

EVALUATINGYOUR RESULT

Basal rates are correct ifBG does not increase ordecrease more than 30-40mg/dl during evaluation.If BG increases: Your basalrate needs to be increasedfor this time frame. If BGdecreases: your basal rateneeds to be decreased forthis time frame.

Same as above

Same as above

Same as above



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Divide the day into 4 time frames and evaluate one at a time —overnight, breakfast, lunch, and dinner. Begin with the overnightbasal evaluation.

During the day of a basal rate evaluation: no exercise or alcohol.

Your last meal, prior to the evaluation, should be one for which the foodbolus can be easily and accurately determined. Choose low-fat foods forthis meal. Eat no food during the basal evaluation time period.

Basal rate evaluations can begin 4-5 hours after the last bolus dose wastaken.

Blood glucose should be between ~100-150mg/dl at the beginning ofthe evaluation in order to proceed.

Stop the evaluation if your blood glucose values go above or below yourtarget range. Treat any low or high blood glucose as usual.

During a basal rate evaluation, generally blood glucose levels shouldbe checked every 1-2 hours. For the overnight time frame, blood glu-cose should be checked before bedtime, midnight, 2-3am and uponwaking.

Do not plan a basal rate evaluation during illness, unusual stress, orafter a severe low blood glucose reaction.

Keep detailed records so your physician and/or diabetes educator canhelp you to evaluate the information and assess your basal rates.

Use the information obtained from the basal rate evaluations to fine-tunebasal rates.

Fluctuations of more than 30-40 mg/dl during a basal evaluation, indicatesthe need to adjust basal rates.

It is best to see a repeating trend before making a basal change.

Make small changes, typically .05 to .10 units/hour.

The basal rate should be increased or decreased 1-2 hours before the bloodglucose begins it’s rise or fall.

Make one change at a time, and then re-evaluate that time frame.

Check with your physician and/or diabetes educator prior to changingbasal rates. Eventually, they may expect you to make your own basal rateadjustments.

Remember, the goal is to find the basal rate segments that work the bestmost of the time. Don’t expect perfection!

f

f

f

f

f

f

f

f

f

f

f

f

f

f

f

f

guidelines for

AdjustingBasal Rates

While everyreasonable pre-

caution has beentaken in the preparation of

this document, the author andpublisher assume no responsibility

for errors or omissions, nor for the uses made of thematerials contained herein and the decisions basedon such use. No warranties are made, expressed or

implied, with regard to the contents of this documentor to its applicability to specific individuals or circum-

stances. The author or the publisher shall not beliable for direct, indirect, special, incidental or conse-quential damages arising out of the use of or inability

to use the contents of this manual. AnimasCorporation advises patients to always check with

their physician/healthcare professional for advice onspecific treatment of their diabetes.

general guidelines for

EvaluatingBasal Rates


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FriendswithDiabetesOct. ‘05

Alot has changedin the diabetesworld since our

comprehensive YomKippur guidelineswere published in5760. Insulin pumpshave become muchmore widespread,and we’ve alsowitnessed the in-troduction of thetrue long-acting in-sulins, Lantus andLevemir.

Having gained somecollective experiencesince then, we

can safely state that it is possible for those who inject a 24-hour long-act-ing insulin to consider fasting on Yom Kippur. These insulins are much morestable and reliable than older options such as NPH, Lente, and Ultralente(and certainly than the 70/30 or 75/25 insulin cocktails, which are hardlyprecise or predictable enough even for a standard day.)

That said, it is still important to note that the pump remains the preferredtool for an insulin-dependant person who is planning to fast. This is becauseit allow for precise and customized basal (background) insulin adjustments,to match the body’s decreasing need for insulin as the fast wears on. Theseadjustments are impossible with long-acting insulins, which release a flat,fixed amount of insulin throughout the day.

S O M E P R A C T I C A L P O I N T E R SIt is worth stressing that, even on a fast day, one should never entirely skip aninjection of long-acting insulin. Remember, that a high blood sugar during a fastcan be just as dangerous as a low blood sugar! In fact, your insulin needs for thenight of Yom Kippur will probably be the same as on a typical night, especially asthe fast is preceded by a large meal. If you do, however, use a bedtime snack toavoid midnight lows, your nighttime Lantus will need to be reduced. cont. on back page

EVENTS

The annual boys Shabbos was,as usual, a tremendous

source of Chizuk and new infor-mation. On Erev Shabbos,renowned endocrinologist Dr.Maclaren offered a highly educa-tion presentation. Throughoutthe Shabbos, pump educatorsfrom Animas corp. were on handto share helpful facts & answerquestions. Rabbi Pinchos Junginfused the event with deepermeaning and pleasure, as he ledthe boys in inspirational singingand stories well into the night.The program was rounded outwith additional speeches and thecamaraderie that makes theseevents so vitally one-of-a-kind.

This year’s girls Shabbos was aresounding success. Much

thought and effort was investedinto an exciting and enlighteningprogram, which was matched onlyby the pleasure the girls derivedfrom each others company. Somehighlights of the event were a fas-cinating personal account byRabbi Chaim Daskal, a phenome-nal interactive workshop present-ed by Mrs. Weingarten, and acomedy performed by some ofthe girls. The participants left forhome still heady from the manynew experiences packed into anamazing day. cont. on back page

G I R L S S H A B B O S

eFasting on Yom KippurA Guide for Users of 24-Hour Insulins

CAUTION: As usual we remind our readers not to make insulinadjustments based solely on ideas expressed in this article. Instead, usethem as starting points for a thorough discussion with your doctor.

Friends With Diabetes, 31 Herrick Ave., Spring valley, NY 10977 • 845.352.7532 • www.FriendsWithDiabetes.org

B O Y S S H A B B O S

Although initially approved as a 24-hour insulin to be administeredat bedtime, many people have found that Lantus works better forthem if taken in the morning, or even twice a day. Here are somepractical suggestions for handling a fast on the various regimens:

• If you are taking your long-acting insulin as a single dose at night, you willneed to decrease it as prescribed by your doctor. Commonly, the dosewill be reduced by a third (although the reduction can vary significantly).If you normally take 24 units of insulin, for example, you might inject only18 units. Note that by doing so, you will be receiving less insulinovernight as well, a correction dose of short-acting insulin might be nec-essary in the morning. Resume taking your regular dose following the fast.

• If you evenly split your long-acting insulin into a morning and eveningdose, you will probably need to reduce only the morning dose. You mayneed to cut back a third, half, or even two-thirds of your usual insulinamount. If this is your first attempt at fasting, play it safe and eliminatetwo-thirds of your normal dosage. You can always correct using short-acting insulin if your blood sugars rise above acceptable levels.

If your dose is unevenly split, you may need to reduce both dosages by dif-ferent amounts.

• It is trickiest if you take your long-acting insulin as a single morning dose.Here’s one idea: Take your regular dose on Erev Yom Kippur. On themorning of the fast, take one-third of your normal dose, and compen-sate by taking an additional third of your long-acting insulin dose afterthe fast (you will be splitting your dose, although you don’t normally doso.) Beware that, even if you implement this plan, it may still take sever-al days for blood sugar to return to normal.

P U M P I N G O N Y O M K I P P U R :a n e x a m p l e

Due to the depletion of glycogen, the body’s stored glucose insulin needsmay drop significantly throughout a

fast day. A pumper might reducehis normal basal rate by 20%

starting early morning,30% over the next few

hours, 40% at noontime, and even 50% bylate afternoon.

When FWD organized a gathering inBrooklyn for parents of children with

diabetes, it is unlikely that anyone antici-pated the wealth of information and chizukthat would be gleamed. The room was won-derfully appointed with a display of gamesand books for families dealing with dia-betes. Presentations were offered by Dr. Tenof Maimonides hospital and representativesfrom Animas and Lifescan corp. As usual,Rabbi Meisels captivated the audience withpractical pointers in his engaging style. Theevening was truly crowned with a magnifi-cent speech by Rabbi Pinchos Jung. In thewords of on couple who came in all the wayfrom Pittsburg, “the entire thing was worth-while just to hear Rabbi Jung speak”.

Children with diabetes ages 6 to 12, andtheir parents, benefited tremendously

from a unique night out. Treated to a dinnerin a retardant, the young participantsreceived a hands-on and very age-appropri-ate lesson on counting carbohydrates infood. Many expensive prizes were raffled offat the event, and all participants left boast-ing a bag full of goodies, priceless nuggetsof education, and the widest smiles around!

Longing to be together again, even for justa short while, 30 boys were delighted to

gather one Motzei Shabbos. Rabbi AryehEisenberg shared his positive approach todealing with lifes’ challenges, in a warmly-accepted speech. The event also featured aslide presentation on advanced pumpoptions. Animas representative ScottScolnick present that night, asserted that henever saw such an advanced and well edu-cated group. Thank you, Friends WithDiabetes, for doing it again!

Grabbing the opportunity before the startof summer camp, several teenaged girls

with diabetes gathered in a Monsey park.They were treated to an informative presen-tation on summer-related topics by Jewishpediatric endocrinologist Dr. Lebinger. Thegirls also wrote letters of encouragementand friendship to each other which weremailed out later during the summer.

P A R E N T S G A T H E R I N G

cont. from page 1 cont. from page 1

SUPPER FOR YOUNG MEMBERS

B O Y S M E L A V A M A L K A H

G I R L S T R I PNormal8 AM to 10 PM= 1.0

Yom Kippur8 am = 0.811 am = 0.72 pm = 0.65 pm = 0.5

Nutrition: The Real Facts

Diabetes in the Media

6

16

21

Some Fascinating FASTING Facts

Wishingall of you aKesivah Vechasimah Tovah

GoinGF rWarDFFriends With diabetes

Fall ‘07 jWxa, hra,Volume I Issue 4

Nutrition: The Real Facts21

Going ForWarD | 6 | Fall 5768

i f you are confronting a decision regarding fasting on Yom Kippur,

we urge you to consult our compre-hensive Tishrei 5764 guide. A Yid-dish version is also available (Tishrei 5761) and additional information on the topic was published in separate pamphlets (Tishrei 5763 and 5766).

Now It’s offIcIal!With the proper precautions, we’ve always insisted that fasting with diabetes is feasible… and now we can finally prove it! believe it or not, a bona fide study was actually conducted on the topic and pub-lished in the prestigious journal diabetic Medicine (October 2006).

a group of israeli doctors followed 56 subjects who were attempting to fast on Yom Kippur. the result? Most participants managed to successfully complete the 25-hour fast. the researchers associate suc-cessful outcomes with those who had greater insulin reductions, and surprisingly, with people who had higher hemoglobin a1cs. (We imagine that’s because those in-dividuals are usually resistant to insulin and therefore less likely to experience a low blood glucose.) but if your a1cs are in range, do not despair! remember to de-crease your insulin doses very generously, especially as the fast day wears on.

some noteworthy details of this study‘s protocol: subjects were

soMeFascinatinG FastinG Facts

Fall 5768 | 7 | Going ForWarD

instructed to lower their insulin by as much as 75%, while aiming for a higher target blood sugar than they normally would. in some cases, doctors even instructed patients to take 25% less insulin for the last meal before the fast. (remember that this meal calls for very precise carb counting. even if you don’t administer less insulin, you certainly can’t afford to over-bolus for this one!)

ExcEptIoNs applybecause no two individuals with diabetes- or their treatment plans- are alike, you still need to get your doctor’s and your rav’s approval before attempting to fast on Yom Kippur. there is, for example, one group of patients with type 1 dia-betes for whom fasting tends to in-duce high blood sugars combined with large ketones and nausea. dr. don Zwickler explains that this rare reaction is triggered by stress hormones released because of the fast, and these people can not fast under any circumstances.

prEvENtIoN Is thE BEst curE

On Yom Kippur, there’s one thing you really want to have a lot of:

glycogen, the body’s stored sugar. in the absence of food or drink, this glycogen will fuel your body and prevent blood sugars from drop-ping too low. dr. Zwickler posits that the reason some people have a greater tendency toward low blood glucose is because their bodies naturally store less glyco-gen. he suggests that, starting three days before Yom Kippur, all potential fasters exercise extreme caution to avoid low blood sugars. Low blood sugars usually signify that glycogen stores are inad-equate and need to be repleted.

fastINg vs. frEquENt Bg chEcks

should a person fast on Yom Kip-pur even if this will require an increased number of blood sugar checks? Our rav has ruled un-ambiguously: One should check blood sugars as often, (and only as often,) as is necessary in order to be able to fast on Yom Kippur. (this is based on his previously-published opinion that checking blood sugars on shabbos or Yom tov with a shinui is a rabbinic pro-hibition, while fasting on Yom Kip-pur is a biblical command.)

in fact, because every change in regimen can trigger the unknown,


it is likely that a person who eats pachos m’kshiur (“less than the measure”, as elaborated below) on Yom Kippur will also need to perform more blood sugar checks than usual. Which brings us to the additional point that there really is no “usual”, because the amount of times most of us check our sugars varies greatly from one day to the next. in conclusion, for both the halachic and logical reasons stated, one should not refrain from fasting on Yom Kippur due to additional blood sugar checks.

tIps for thE typE two

n extended release medications are especially formulated so that they are absorbed by the body

gradually over a period of time. if you take extended release medi-cations, you may want to ask your doctor about a possible dose re-

duction during the day preceding the fast, and certainly on Yom Kip-pur itself. On an empty stomach, these medications pose a threat of low blood sugar.

n despite the hassle, how about performing a fasting trial run? You might eat an earlier supper one night (about the same time the seudas hamafsekes will be con-sumed) and refrain from eating again until morning, while check-ing your blood sugars periodically. You’ll feel reassured if you verify that your blood sugars can really remain stable while fasting.

sImplIfIEd solutIoNYom Kippur is almost synonymous with fasting, but not everybody can take that for granted. there are various scenarios in which

fasting is con-traindicated and a rav might instruct that food be eaten pachos m’kshiur, in amounts not considered ‘eat-ing’ according to halacha. in this situation, a certain

amount of food is allowed every 9 minutes, while a specific amount of drink is permitted every 5 min-utes. sounds complicated?

eat and drink

drink

eat and drink

drink

eat and drink

drink

eat and drink


You can use a clock to make things simpler: start on the hour (for ex-ample 10:00) by eating and drink-ing the allowed amounts. Five minutes later, drink, but do not eat. When the next five minutes elapse, consume both food and drink, and five minutes later, it would be back to only drinking. in this way, con-tinue alternating every five min-

utes; first eating and drinking and then only drinking.

Our final wish is that this article be completely outdated by the time Yom Kippur arrives. May we merit to fast along with the rest of klal yisroel, hale in body and whole in spirit, with the coming of Moshiach tzidkeinu! n

simplified solution illustrated

redconsume allowed

amount of food and allowed amount of drink

Greenconsume allowed

amount of drink only

Yom Tov Delights

Soul Monitoring

6

16

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Fasting with Type 2

GoinGF rWarDFriends With diabe tes

Fall 5769 y"xa, hra,

Volume III Issue 1

OurSponsors:

as i was reviewing the material in this issue, i was suddenly struck

by the unbelievable turnabout we’ve witnessed in diabetes attitudes and standards of care. Unexpectedly, i found myself taking a mental journey through memories and musings of a seemingly different era… really, just a few short years ago. So many of yesterday’s prevailing norms have been completely shattered and people with diabetes have, over recent years, literally received a new lease on life.

Gone are the days when diabetes equaled an unyielding regimen which completely ignored the reali-ties of daily life. once upon a time, anybody taking insulin had to arise at a specified hour to administer an injection, and then eat and snack at precise intervals throughout the day. How well i remember the family out-ings during which our entire group was forced to declare periodic rest stops so that i could take my insulin and eat a full meal… even though nobody was hungry yet.

Gone are the days when people with diabetes were enslaved to strict meal plans, which mandated exactly what to eat at each meal. if your doctor prescribed 40 grams of carbohydrates for lunch, then you had better meet the quota… it mattered little whether you were actually hungry or if you abhorred the Yeshiva’s lunch that day. (and remember the “exchange system”,

still popular ten years ago? i have some old brochures with lengthy lists detailing how many cherries are in one “fruit exchange” and how much rice is in one “starch exchange”.)

Gone are the days when, despite the monumental sacrifices made, blood sugar control was erratic and unpredictable, at best. it was almost impossible to adequately target a predawn blood sugar rise or a post dinner high. random highs and lows were par for the course, and unfortu-nately, people with diabetes suffered the debilitating consequences. When i stop to think about it, i am awed at the dramatic revolution we’ve wit-nessed in methods of insulin delivery and diabetes control. The resulting improvements in quality of life and health are equally impressive.

and gone are the days when doctors gravely shook their heads and informed us that people with diabetes simply cannot fast. as one diabetes myth after another is laid to permanent rest, we have seen a complete change of attitude in this arena as well. Today, rabbanim and doctors acknowledge and respect that diabetes does not prevent us from leading normal lives in every way. and that includes fasting on Yom Kippur.

This time last year, we shared a study on Type 1 diabetes and pro-longed fasting by Dr. David Zangen. That study, which was published in DiaBeTiC Medicine, clearly

demonstrated that people with diabetes generally have no problem on a fast day, if they are adequately prepared. in this issue, we present a fascinating report by Dr. Martin M. Grajower, MD, FaCP, FaCe which reinforces this truth, outlining guidelines for patients with diabetes to fast safely. You’ll also enjoy reading actual fasting ex-periences shared by people in our group. let us know how your Yom Kippur passes this year, and maybe you’ll find your story in next year’s magazine! (names and details are always altered, of course.)

in conclusion, let’s remember that there are exceptions to every rule. one of the greatest discoveries in the field of diabetes is that no two people are alike, and each individual requires a flexible, custom-tailored protocol of care! if your rav or doctor does not grant you permission to fast this Yom Kippur, then that’s the ultimate way for you to spend this holy day.

Wishing you all a truly cleansing Yom Kippur and a thoroughly sweet new year,

Rabbi Hirsch Meisels

sWxcForeWord



INTRODUCTION One of the challenges of patients with diabetes is fasting on Yom Kippur and the other five fast days. Until recently, there were no published guidelines for doctors or diabetes educators to follow. Many patients were therefore ad-vised by their doctors not to fast, for fear of developing hypogly-cemia ( low blood sugar). In April, 2008, i published an article for dia-betes professionals (Grajower, MM: “Management of Diabetes Mel-litus on Yom Kippur and Other Jewish Fast Days”, Endocrine Practice 2008; Volume 14, pages 305-311) which contains general concepts and specific guidelines on managing both types 1 and 2 patients during a fast day. these

guidelines were based on my 30 years of experience practicing en-docrinology as well as an under-standing of how currently avail-able drug therapy works.

in this article, the guidelines are re-written for patients, and the focus is just on type 2 diabetes. a person with type 2 diabetes is, by definition, insulin resistant, mean-ing although the body makes insulin, it is resistant to using the insulin effectively. it has long been known, that the most effective way to reverse this insulin resistance is by restricting the intake of all car-bohydrates. studies have previ-ously shown that a type 2 diabetic who fasts will normalize his blood sugar, yet will not develop a low blood sugar (hypoglycemia). Thus, the only way a type 2 diabetic can become hypoglycemic while fast-ing is as a result of taking medicine that lowers blood sugar. it there-fore stands to reason that as long as these medicines are out of the body during the fast, the person should be able to safely fast.

gUIDelINes:

FasTINgwith Type 2 diabetes

MaRTIN M. gRajOweR, MD, FaCp, FaCe

Rabbi Meisels comments: This article has been shortened and revised from its original version based on discussions between Dr. Grajower, Rabbi Weissmandl and myself. The recommendations in this ar-ticle are in keeping with both the halachic rulings of Rabbi Weissmandl as well as the medical opinions expressed by Dr. Grajower in the original paper published in Endocrine Practice.

ON yOM KIppUR aND OTheR FasT Days


in contrast, a type 1 diabetic is insulin deficient, and therefore must take insulin in order to sur-vive. type 1 diabetics must have insulin on board during a fast day, but must carefully regulate the amount of insulin so as to avoid a low blood sugar. this differ-ence between type 1 and type 2 diabetics (even type 2’s on insulin) raises certain halachic issues which we will not address here. Conse-quently, this article addresses only type 2 patients.

When patients with diabetes ask their doctors whether they may fast, they should expect the doctor to have knowledge of the scientific facts, an understanding of that patient’s health, and a sensitiv-ity to the religious feelings of the patient. When physicians have carefully considered the individual needs of each patient, rather than issuing a blanket statement that “patients with diabetes should not fast,” Jewish law would gener-ally mandate that patients listen to their physicians, especially those who are specialists.

as an Orthodox Jew and practicing endocrinologist, i try to synthesize Jewish law with good medical practice. each year, rabbis call me regarding people with diabetes who were told by their physicians (including endocrinologists) not to fast. My nearly 30-year experience has been that, from the perspec-tive of blood glucose alone, almost all patients not taking insulin can

safely fast. the vast majority of pa-tients taking insulin can also safely fast, again with consideration of just blood glucose control.

CONCepTs during the past decade, the treat-ment of diabetes has become quite complex with the introduction of many new medications. accord-ingly, i believe that understanding certain concepts would be helpful before outlining my approach to the individual patient.

Most importantly, because each patient will be fasting as infre-quently as once a year (Yom Kip-pur) and up to a maximum of 6 times, the main objective is to avoid a low blood sugar, which would require the patient to end the fast.

One major difference among med-ications is that some lower ‘basal’ sugar (the reading approximately 3 hours after a meal until the next time food is eaten), and some low-er ‘prandial’ blood glucose levels (the readings within 3 hours after eating). In addition, there is a wide variation in their duration of action. some medications have an effect lasting 24 hours, while others work for only several hours. similarly, when insulin doses are adjusted, the main consideration is the du-ration of action of the prescribed insulin. therefore, before the four daytime-only fasts, because the patient eats normally the night


before the fast, no need exists for reducing any short-acting pran-dial evening medications. One exception is if the patient tends toward a low blood sugar during the night or early morning; in such a case, i would reduce the dose of the medication (tablets or insulin) that is likely causing this low blood sugar. in contrast, because prior to Yom Kippur and tisha b’av the patient may eat dinner earlier than usual and will not have a bedtime snack, the before-dinner medica-tion may need to be reduced to avoid a low blood sugar during the night.

On the morning of the fast, patients with type 2 diabetes rarely need medication. even if the blood glu-cose level is high, the absence of eating any carbohydrates will im-prove insulin sensitivity and there-by lower the blood sugar level.

a final consideration is the poten-tial for each medication to cause a low blood sugar, either alone or in combination therapy. Certain medicines are glucose-dependent, meaning their effect is relative to the existing blood sugar; when the blood sugar is high, these medi-cines are very active whereas as the blood sugar falls, the effect of the medicine diminishes. When used alone, therefore, these medicines rarely cause a low blood sugar. examples of glucose-dependent medicines are metformin, avan-dia (rosiglitazone) and Actos (pioglitazone), as well as Januvia (sitagliptin), the first of a new class

of drugs called dPP-4 inhibitors, and byetta.

the other main therapeutic ob-jective is to avoid hypotension (low blood pressure), especially in older patients. everyone who re-frains from eating and drinking for 25 hours will become dehydrated, and many otherwise healthy peo-ple will experience a decrease in their blood pressure as a result. in my 30-year experience in practice, the most common reason a patient with diabetes could not complete a fast was not due to a low or high blood sugar but because of dehy-dration and resultant hypotension. therefore, one of my criteria for advising a patient with diabetes not to fast is my concern regarding dehydration. examples of such sce-narios would be a patient who has had considerably out-of-control blood glucose levels during the 2 weeks before the upcoming fast, a patient with a recent “stroke,” or a cardiac patient who tends to run low blood pressure.

there are other conditions which may make it unadvisable for a per-son with diabetes to fast. some of these conditions, such as cardiac disease, adrenal insufficiency, and kidney disease, to name a few, can exist without diabetes, but may pose an increased risk in a person with diabetes. these conditions are not addressed here as they are beyond the intended scope of this article. It is important that patients review ALL their medi-cines with their doctor prior to fasting.


gUIDelINes as mentioned, the main objec-tive is avoiding a low blood sugar. should the blood sugar drop too low and the patient must eat, then the therapeutic plan did not ac-complish its purpose. On the other hand, should the blood glucose level increase during the course of one day up to about 300 mg/dl, it will not create either a short-term or a long-term problem (see pregnancy exception discussed subsequently). If anything, as men-tioned earlier, fasting itself has been shown to quite effectively lower the blood glucose level. at the same time, fasting in the ab-sence of any diabetes medications

will never cause the sugar to drop below the normal range.

i continue all medicines as usual the morning before the fast day. i do not give any glucose-lowering medication (except insulin; see subsequent information) on the day of the fast itself. After the fast is over, i resume all medica-tions at their usual times (that is, I do not have the patient take a tab-let at night that normally would have been taken that morning). the following guidelines refer to medication taken either at lunch or later on the day before the fast and to insulin on the day of the fast itself (Table 1).

Type 2 not on insulin(includes injectable incretin mimetics)* Type 2 on insulin and oral agents Type 2 on only insulin

Day Before begin-

ning at lunchtime

Don’t take sulfonylureas* or DPP-4 inhibitors*; take all other medications normally taken before lunch and supper.

Don’t take sulfonylureas*; take all other medications before the last meal. Take usual dose of short-acting insulin before supper, and one-half to one-third the usual evening dose of intermediate- acting or basal insulin.

Take usual dose of short-acting insulin before supper, and one-half to one-third the usual evening dose of intermediate acting or basal insulin

Yom

Kip

pur a

nd Ti

sha B

’Av

Day of Fast Don’t take any medications. Don’t take any medications including insulin.

Don’t take any insulin unless blood sugar is above 250 mg/dL (then take some short-acting insulin analog and aim to lower only to 110-140 mg/dL range.).

After the Fast

Resume all usual pre-supper and bedtime medications. Do not take any missed medi-cines from the morning.

Resume all usual pre-supper and bedtime medications. Adjust the dose of the short-acting insulin if the patient feels he will be eating a smaller supper than usual.

Resume all usual pre-supper and bedtime doses; adjust the dose of the short-acting insulin if the patient feels he will be eating a smaller supper than usual.

Day Before begin-

ning at lunchtime

Don’t take sulfonylureas or DPP-4 inhibitors; take all other medications before the last meal.

Don’t take sulfonylureas; take all other medica-tions before the last meal. Take usual dose of short-acting insulin before supper; reduce the dose of the intermediate acting or basal insulin by 20%.

Take usual dose of short- acting insulin. Reduce intermediate or long-acting insulin to about 80% of the usual dose.

Dayt

ime-

only

Fast

Day

s

Day of Fast Don’t take any medications.Don’t take any medications including insulin. Take short acting analog insulin if blood sugar > 250 mg/dL.

Don’t take any insulin unless blood sugar is above 250 mg/dL (then take some short-acting insulin analog and aim to lower only to 110-140 mg/dL range.).

After the Fast

Resume all usual pre-supper and bedtime medications. Do not take any missed medi-cines from the morning.

Resume all usual pre-supper and bedtime doses. Adjust the dose of the short-acting insulin if the patient feels he will be eating a smaller supper than usual.

Resume all usual pre-supper and bedtime doses; adjust the dose of the short-acting insulin if the patient feels he will be eating a smaller supper than usual.

Table 1: Guidelines for adjusting diabetes medications surrounding fast .

*See Table 2 for names of specific medicines.


Medicines that lower blood sugar but never below the normal range, can be taken as usual. examples are metformin, actos, and avandia. Januvia and other dPP-4 inhibitors soon to be marketed when they are the only diabetes drug being taken rarely cause a low blood sugar , but can result in a low blood sugar if used in combination with any other sugar-lowering medica-tion. because their effect lasts for 24 hours, they should not be taken later than with breakfast before the fast day. Other medicines with a long duration of action, such as sulfonylureas (examples: gly-buride, glipizide)(Table 2), should also not be taken later than the morning before the fast because their prolonged action extending into the day of the fast could cause a low blood sugar. Medications with a shorter duration of action, such as Prandin, starlix, byetta, and symlin, can be taken before lunch or supper on the day before the fast, inasmuch as these will be the patient’s normal (or even in-creased) meal.

Patients need be extra careful in that many currently available medicines are combinations of two different blood sugar-lowering agents (Table 3). Each component

of these combination pills needs to be considered individually.

Patients with type 2 diabetes who require insulin always need to ad-just their dose beginning with the evening before the fast. in general, the degree of glucose control dur-ing the 1 to 2 weeks preceding the fast day will influence the reduction in the insulin dose. bolus or short-acting insulin (Apidra, Humalog, NovoLog) should be taken as usual before supper on the night before the fast. i always aim to use some basal insulin (Lantus, Levemir or NPH) during the fast (regardless if the basal insulin is taken at night or in the morning). I reduce the dose to one-third to one-half of the usual dose (based on the A1C) for Yom Kippur and tisha b’av. For the daytime-only fasts, i reduce the dose to about 80% of the usual basal insulin dose. the better con-

Table 3 CoMBinaTion DrUGS: consider each drug separately

NAme Combination

Duetact glimepiride+Actos

Avandamet Avandia+metformin

Actoplusmet Actos+metformin

Avandaryl Avandia+glimepiride

Janumet Januvia+metformin

Metaglip Glipizide+metformin

Glucovance Glyburide+metformin

SULFONYLUREAS bIGUANIDEStHIAZOLIDIN-

EDIONES GLITANIDESINCRETIN MIMETICS DPP-4 INHIBITORS

Glucotrol (glipizide)Glucophage, Glumetza metformin Actos (pioglitazone) Prandin (repaglinide) Byetta (Exenatide) Januvia (sitagliptin)

Amaryl (glimepiride)Avandia (rosigli-tazone) Starlix (nateglinide) Symlin (Amylin) Liraglutide

DiaBeta, Glynase PresTab, Micronase (glyburide)

Table 2: list of currently available diabetes medications: Brand names (generic names)

(continued on pg. 13)


trolled the blood glucose levels are preceding the fast, the less basal insulin i recommend. i also reduce the dose of evening basal insulin if the patient normally has a bed-time snack, inasmuch as the snack will not be taken the night of Yom Kippur or the tisha b’av. after the fast, bolus or short-acting insulin should be taken prior to eating. because many people will actually eat less than their usual amount at this meal, a slightly reduced dose may be indicated if this is the case; on the other hand i would nOt increase the dose to compensate for a larger meal so as to avoid overcompensating and causing the sugar to drop too low.

When in doubt about how much insulin to recommend, i err on the side of a lower dose. a high blood glucose level can be subsequently corrected without “breaking” the fast by having the patient take ad-ditional small doses of short-acting insulin.

The combination insulins (70/30, 80/20, 75/25, 50/50, Mix) pose a slightly more difficult adjustment. i generally reduce the dose to one-half to one-third of the usual dose, depending on the A1C. Ideally, the patients would take just the intermediate component of the combination insulin on the morn-ing of the fast day. this approach, however, would entail buying ad-ditional insulin. therefore, i tend to under-treat rather than over-treat these patients.

Patients with an insulin pump should not administer a bolus

of their insulin once the fast has begun (unless the blood glucose level exceeds 250 mg/dL). They should decrease the basal rate by about 10% beginning in the early morning (earlier if they normally take a bedtime snack) and increase the frequency of blood glucose testing, especially the first time they fast using the pump. they may need further reductions as the fast day progresses. [editor’s comment: for a detailed plan for adjusting insulin for those on a pump see article “magic numbers: the Yom Kippur basal calculator” in this booklet.]

DealINg wITh a lOw BlOOD sUgaR ON The

FasT Day the rules regarding eating and drinking on Yom Kippur differ from the other Jewish fast days. accordingly, on Yom Kippur if patients have symptoms of a low blood sugar, or document a blood glucose level of less than 60 mg/dL, i advise them to take one of the commercially available glu-cose tablets or winkies (rather than real food or drink) and to retest the blood glucose in 15-30 minutes. if the blood sugar remains low for a 1-hour period, the fast should be discontinued and food eaten. My threshold for recommending that the fast be terminated is inversely proportional to the age and gen-eral health of the patient. On the other Jewish fast days, because Jewish law views any oral intake as terminating the fast, i advise

(continued from pg. 10)


patients simply to break the fast if symptoms occur or the blood glu-cose level decreases below 60 mg/dL.

CheCKINg BlOOD glUCOse ON yOM KIppUR

Yom Kippur differs from the other fast days also in that there is a pro-hibition against drawing blood and using electrical devices (such as blood glucose meters), unless necessary to preserve the sanctity of life. therefore, when any pos-sibility of a low blood sugar ex-ists, the blood sugar should be checked, and as often as the pa-tient feels necessary. the follow-ing should therefore be viewed as general guidelines only.

Patients taking no diabetes medi-cations are not at risk for develop-ing a low blood sugar and there-fore need not check their blood glucose level during the entire 25-hour fasting period. Patients taking antihyperglycemic (blood sugar lowering) drugs (excluding insulin) who are known to have good a low blood sugar awareness, meaning they always feel when the sugar is either low or dropping rapidly, and have adjusted their diabetes medicines as described previously, also need not check their blood sugar level, unless they begin to have symptoms (some of the symptoms usually associated with low blood sugar, such as rapid heartbeat, could represent dehy-

dration and low blood pressure, and the blood glucose should therefore be checked). Elderly pa-tients or those with documented low blood sugar unawareness should check their blood glucose level upon arising on the morning of the fast and then every 4 to 6 hours (sooner if glucose values de-cline below 70 mg/dL), unless their only medications are those that do not cause a low blood sugar (as discussed previously).

i recommend that all type 2 pa-tients taking insulin test their blood glucose level upon arising on the morning of the fast and then every 4 to 6 hours (sooner if glucose values are below 70 mg/dL or the patient has symptoms suggesting low blood sugar). I advise supplemental rapid-acting insulin analogues (Humalog-lispro, novolog-aspart, or apidra-glulisine; NOT regular insulin) for blood glucose levels greater than 250 mg/dL; i try to aim for a blood glucose value in the range of 110 to 140 mg/dL.

wRITTeN ReCOMMeNDaTIONs

On the basis of my experience, i recommend that the physician or patient write down the recom-mendations that are made. in these written recommendations, i include the following informa-tion: (1) changes in medication before, during, and after the fast, (2) frequency of blood sugar test-ing, and (3) “what if” planning for terminating the fast if the blood


glucose level declines below a specific value or the patient has symptoms of low blood sugar. besides improving the likelihood that the patient understands and will follow the plan, the written recommendations become a part of the patient’s medical records. i will generally follow-up with the patient at the next office visit to learn how the patient fared on the fast day and note these comments for use at subsequent fasts.

pRegNaNCy in pregnant women with diabe-tes, whether gestational or pre-existing, the diabetes is controlled by either diet, glyburide, or insu-lin. For those with diet-controlled diabetes, there appears to be no difference during fasting than for nondiabetic pregnant women; fasting should, if anything, improve their diabetes control without an increased risk of a low blood sugar. therefore, a pregnant diet-con-trolled woman with diabetes can fast on Yom Kippur (only), in the case where the rav and the doctor agree for her to do so [see Rabbi Meisels comment in the beginning of the article].

if the pregnant woman is on gly-buride, it should not be taken after breakfast the day prior to Yom Kippur. a pregnant woman receiving insulin is an exception to the general considerations already outlined; in such patients, we try to avoid any days of hyperglycemia because of the potential harmful effects on the fetus. accordingly, i

do advise a pregnant woman with either gestational or preexisting diabetes who is receiving insulin therapy not to fast.

CONClUsION it has been my experience that the overwhelming majority of patients with diabetes can, from the per-spective of blood glucose control, safely fast on Yom Kippur or one of the other fast days. in the absence of any previously published guide-lines, i have outlined my approach to adjusting the currently avail-able hypoglycemic agents, with the main objective being to avoid a low blood sugar. i have described several concepts that should help clinicians advise patients when new hypoglycemic agents become available. Finally, i would recom-mend that patients discuss with their clinicians prior to a fast day how to adjust their medications. this discussion would prevent the patient from relying solely on personal judgment and possibly taking too much medication, with the resultant development of a low blood sugar. at the same time, if the clinician tells the patient nOt to fast on a particular fast day, the patient should make sure that such a recommendation is made based on his individual situation, rather than reflecting an attitude of the doctor to prohibit fasting in all patients with diabetes.

no portion of this article may be reprinted without written permission from Dr. Martin Grajower. Questions and comments can be sent to Dr. Grajower at [email protected] or 3736 Henry Hudson Parkway, Bronx, nY 10463. n


Having experienced ten Yom Kippurs on the insulin pump,

my fasting preparations are some-what predictable. i begin by dig-ging out my records of last year’s fast (Yes, I keep them faithfully!) which indicate the exact basal rate reductions implemented, alongside my resulting blood sugars. after analyzing them care-fully, i start working on a new basal profile, incorporating any lessons learned from the previous year’s effort. My fasting basal rates gen-erally resemble my regular rates at the beginning of the fast, but then they gradually decrease, as the day wears on and my body’s store of glycogen is slowly depleted. so i sit for a while, making endless calculations, writing and erasing numbers in quick succession, and finally, settling on an altered basal rate which, i hope, will result in a problem-free fast day.

that’s the mechanical routine.

but there’s a well-practiced emo-tional component to this annual exercise. each year anew, i am flooded with anxiety and reluc-

tance, as i approach the monu-mental assignment of calculating my fasting basal rates. every year, i push off the task as long as i can; only tackling it at the last pos-sible moment with a prayer on my lips. the enormity of my decision weighs heavily on me, and i am quite put off by the mathemati-cal aspect as well. i am surely not the only pumper who dreads ma-nipulating all those numbers and wishes there was an easier way to do it.

and now there is!

FWd’s basal calculator is a Mi-crosoft excel spreadsheet, pro-grammed and individualized by you, that flawlessly performs the math equations to calculate your fasting basal rates. You record your regular basal rates and the amount by which to reduce them for Yom Kippur, and… presto! the basal calculator will present your Yom Kippur basal rates! in fact, this special calculator comes pre-programmed with a standardized formula for basal rate reduction,

The Yom Kippur Basal Calculator

Exclusively for insulin pump-ers who have permission to fast on Yom Kippur


In Column B, record your regular basal rates, making sure to enter a basal rate for each hour on the table.

Column C is where you insert the percentage by which you want to reduce each basal rate. Figure this one out using your own previ-ous experiences, a good dose of common sense, and your doctor’s expert advice. Remember that in-dividual needs do vary, according to the amount of glycogen stored in the body.

Column D displays the final results: your new fasting basal profile.

the spreadsheet comes preprogrammed with specific reductions that gener-ally work for many people. it is set to reduce basal rates only slightly overnight (when we assume our insulin needs are still as usual, but we’d rather wake up with a somewhat elevated blood sugar level), and then, basals are gradually lowered in 10% increments throughout the ensuing daytime hours. although this logical formula has been used successfully, dO nOt assume that the pre-programmed values will be suitable; figure out, together with your doctor, what will work best for you.

Okay, we’ll admit it! the basal calculator is not the simplest solution for every-body. People who use a single flat basal rate throughout the year, Or those who will be lowering their basals by the same amount over the entire fast day, can simply perform the math mentally and program a temporary basal rate. but, for the rest of us, this nifty calculator can be a real help.

The basal calculator is avail-able from Friends With Dia-betes only by email, upon request.

Here’s how it works:

BasalCalculator

“[Last year,] I set my fasting basals using the formula provided by FWD’s basal calculator, and I want to thank you very much for this wonderful tool. I had my easiest fast ever! In the past, I reduced all my basal rates by 20% across the board, but I always ended up going too low. This year, I needed to treat a low right at the beginning of the fast, but after that, I was amazed at how stable my numbers remained throughout the day.”

– Yerachmiel C.


which you can simply leave, if it is appropriate for you.

When it comes to fasting, insulin pumpers are at a unique advan-tage. Unlike those who take mul-tiple daily injections, the insulin infused by pump is of only one type (rapid-acting) and unambigu-ously divided between basal and bolus. this makes it much easier to deduct uniform amounts from our regular dosages throughout the fast day. in fact, doctors gener-ally prescribe insulin reductions in terms of percentages (Your doctor might suggest, for example, “this Yom Kippur, reduce your basal rates by 25%, and then later by 45 %.”) and this type of instruction is most easily implemented on the insulin pump. and now, using our basal calculator, figuring your Yom Kippur insulin dosages could hardly be easier.

Considerations at the begin-ning and end of the fast

because Yom Kippur lasts longer than twenty-four hours, pump us-ers will find that there is a window of about two hours at the onset of the fast during which the fasting basal rate cannot be used. if, for example, Yom Kippur begins at 6:10 p.m. and

ends at 7:36p.m., then the fasting basal rate will be inadequate from 6:10, when the ta’anis begins, until 7:36 that night (During those hours, the programmed insulin amount is extremely low).

the problem is easily solved by retaining the regular basal profile until 7:36, and only then, switching to the special fasting profile. how-ever, if you are not certain you’ll re-member to make this all-important change, then don’t risk it. rather, start using the fasting profile as soon as Yom Kippur begins, and program a temporary basal rate, equal to your regular basal rate at that hour of the evening, to last until 7:36.

after the fast day is over, most people struggle with high blood sugars as they eat their first meal. For this reason, you may want to revert to your regular basal profile even before the fast is over, if your blood sugars are not low.

FWD takes no responsibility for any negative results incurred due to the use of the described formula or its stated applications. All information is presented only in a suggestive and illustrative manner, and should not be incorporated without a doctor’s prior consent.


Gershonextremely cautious

Dovid Aryeha frightening fasting experience

YerachmielFasting requires commitment


In My Experience…Your Own Yom Kippur Voices

“ i started fasting on Yom Kippur after i went on the insulin pump 9 years ago. but that ended three Yom Kippurs ago, when my blood sugars were in the 70-100 mg/dl range throughout the fast, yet i ended the day with a very frightening case of ketoacidosis. i’ve been told by a professional that the reason i went into dKa despite my low blood sugars, was because my liver did not have enough basal insulin. i’ve never fasted since. ”Editor’s note: Dovid Aryeh’s experience was unusual, yet not unheard of. As we reported in a previous Yom Kippur mailing, there are some people with diabetes who do go into ketoacidosis when fasting, and those people cannot fast under any circumstances.

“ i tackle the fast day by im-plementing a lower basal rate and checking my blood sugars very frequently. When my numbers start dropping, i program a tem-porary basal rate of 0.0 units until my sugars rise again. however, if they dip below 70 mg/dl, then i break the fast and eat something. i think that, in order to fast, an individual must have experience adjusting his own basal rates, and must be committed to treating blood sugars properly if they do

go too low. ”

“ i’ve always managed to fast without serious incident, b”h. i do this by being extremely cautious, keeping my blood sugars above 110 mg/dl, and treating anything under 100 mg/dl as full-fledged hypoglycemia. (In my fasting experience, once I hit 100 mg/dl, my sugars tend to plunge rapidly.) I also make sure to drink a lot before the fast, and test my sugars often- at least every two hours- throughout the fast day. ”


Mimi

Fraidynervou s about checking BGs in Shul

Yitty

Avromi


Blood sugars tend to spike considerably once food is

ingested after the fast, and much has been said about

dealing with this phenome-non. Here’s what YOU had to

say on the matter:

“ i fasted for nine years while on multiple daily injections with Lantus, and last year i switched to the insulin pump. in all cases, i’ve found the fast day to be okay, but once it was over, my blood sugars spiked no matter what strategy i used. i’ve tried doubling my basals beginning one hour be-fore the end of the fast, and then doubling my regular carb ratios… i even played around with the combo bolus to straighten out my blood sugars, but nothing has worked yet. My blood glucose always soars into the 300

mg/dl range, and nothing i’ve tried has made a difference. ”

“ My blood sugars always go up to about 250 mg/dl following the fast, and i gave up trying to pre-vent the rise. i simply admi-nister insulin to bring down the number, and i’m gene-rally okay afterwards. ”

“ i fasted successfully last year by staying home from shul and checking my blood sugars every hour or two. i even managed normal blood glucose readings after the fast was over. but this year, i’d like to go to shul, and i’m much more nervous about keeping adequate track of my numbers so that i can res-pond accordingly and make any necessary changes. ”

“ Over the past 10 years that i’ve been fasting with diabetes, i’ve never had any problems. i picked up an excellent trick from my dia-betes educator for keeping blood sugars in a decent range after the fast. i use the dual bolus pump feature [ed: The dual bolus option, also referred to as the combo bolus later on, is available by various na-mes on current insulin pumps] and divide my full meal bolus in two, taking half the amount immedia-tely, and programming the other half to be administered slowly over the next hour. in addition, i never drink sweetened juices or eat carbohydrate-laden foods im-mediately after the fast, as they do

not agree with my stomach. ”

חולי סוכרת ביום הכיפוריםרקע:

צום בין בריא באדם משתנים בדם הסוכר ערכי בערכים אך הסוכרת חולה אצל גם וכך לאוכל,

גבוהים יותר.

קבועים הם בדם הסוכר ערכי הבריא, באדם אוכל אחרי ,% מג”ר 100 ל- הקרוב צר, בתחום שוב יורדים ואח”כ מה לזמן עולים הסוכר ערכי לערכים הבסיסיים הקבועים. גם בחולה הסוכרתי גבוהים הם אך קבועים בסיסיים ערכים ישנם רמת האוכל ולאחר הבריא, של מהערכים יותר הסוכר עולע הרבה יותר והערכים נשארים גבוהים תקופה ארוכה יותר עד שהם ירודים שוב לערכיים

הבסיסיים של החולה.

לעליה במקביל אכילה, בזמן פיזיולוגי באופן של בהפרשה עליה גם ישנה הסוכר, בערכי הסוכר את מכניס האינסולין מהלבלב, אינסולין הכבד בתוך הסוכר של אגירה ומאפשרת לתאים גליקוגן. הקרוי תשמורת חומר בצורת והשרירים יורדת הסוכר רמת צום, של במצה זאת לעומת בדם וכך גם יורדת רמת האינסולין, במקביל עולים וכתכולאמינים( )גלוקגון אחרים הורמונים בדם היצור ואת הגליקוגן, פירוק את המשפעלים מחדש של סוכר על ידי תאי הגוף. באשר הגליקוגן שעות(, כמה של צום לאחר שקורה )כפי נגמר הרמות הנמוכות של האינסולין מאפשרות שחרור חומצות השומן. רקמת מתוך שומן חומצות של השומן מתחמצות ויוצרות גופי קטו )קטונים( אשר משמשים כדלק תחליפי לפעולת שריר הלב, שאר שבתוך הסוכר ואילו והכליה, הכבד, הגוף, שרירי

זרם הדם, נשאר לפעולת המוח וכרוריות הדם.

חיונית הינה האינסולין של הזו הבסיסית הרמה הדם, זרם בתוך הסוכר איזון על לשמירה ביותר או הבאזאלית, והיא הנקראת גם הרמה הבסיסית האינסולין הפרשת חלה אוכל בזמן זאת לעומת

כתגובה לאכול קרויה גם הפרשה פראנדיאלית.

המאוזן העדין הזה בין הפרשה של האינסולין בזאלי ושל ההורמונים החארים לבין הפרשה פראנדיאלית, למתן זקוקים חלקם ולכן סוכרת, בחולי מופרע

אינסולין להפריש הלבלב את המעוררות תרופות הסוכר של ההטמנה את המשפרות תרופות או אף זקוקים אחרים וחולים הגוף תאי ידי על ניתנים הטווח קצרי האינסולינים אינסולין. למתן מחקים הטווח ארוכי והאינסולינים ארוחות, סביב לאחרונה עד האינסולין. של הבזאלי הייצור את האינסולינים ארוכי הטווח הקלאסים לא היו יעילים האחרונות השנים ב-5 רק הבזאלי המצב בחיקוי כדוגמת מהונדסים אינסולינים לשימוש נכנסו הלנטוס אשר מחקים בצורה פיזיולוגית את ייצור

האינסולין הבזאלי.

הסיכון בצום ממושך

היפוגליקמיה - רמות גבוהות של אינסולין בדם יחד יצור את המעוררים הורמונים הפרשת חוסר עם ונגמר( התפרק )לאחר שהגליקוגן שבכבד הסוכר עלול לגרום לירידה ניכרת של הסוכר בדם ולגרום

לפגיעה בתפקיד המוח.

בחולי - קטו גופי ריבוי עם וחמצת היפרגליקמיה סוכרת עם חוסר מוחלט של אינסולין, צום ממושך יגרום ליצור מתגבר של סוכר ושל גופי קטו בתוך זרם הדם, ללא בקרה )כי אין אינסולין שמאזן אותו( חומצי, נעשה )הדם הדם מופיעה חמצת של ואז זהו מצב יכולים לתפקד כראוי(, אינם ותאי הגוף

מסכן חיים.

התייבשות ונטייה לקרישיות יותר - חוסר שתייה בזמן הצום, עלול לגרום להתייבשות, המצב נכון ביחוד בפעילות העוסקים באנשים ולח, חם באקלים גופנית מאומצת, וכן במצב של סוכרת לא מאוזנת נוזלים. התייבשות ואיבוד יתר הגורמת להשתנות עולולה להחמיר תפקוד של הכליה, ולגרום לעליה ניכרת בצמיגות הדם )עקב ייצור מוגבר של גורמי

קרישה השכיח בחולי סוכרת(.

מצוות התענית ביום הכיפורים

הרמב”ם בסדר זמנים הלכות שביתת עשור פרק א’ סימן ד’ כותב: “מצוות עשה... יש ביום הכיפורים והיא לשבות בו מאכילה ושתייה שנאמר תענו את נפשותיכם. מפי השמועה למדו עינוי שהוא לנפש זה הצום. וכל הצם בו קיים מצוות עשה. וכל האוכל ושותה בו ביטל מצוות עשה ועבר על לא תעשה

oheu,n ohghr | ב | yWxa, hra,

קובץ בית הלל - גליון כ"טקונטרס רפואה והלכה ]דף ע”ד – ע”ו מדפה”ס[ד”ר יוסף קליינמן, מנהל החטיבה הפנימית בי”ח “ביקור חולים”

שנאמר: כי כל הנפש אשר לא תעונה בעצם היום הזה ונכרתה. מאחר שענש הכתוב כרת למי שלא נתענה למדנו שמוזהרים אנו בו על אכילה ושתיה. וכל האוכל או השותה בו בשוגג חייב קורבן חטאת קבועה... ואין חייבים כרת או קורבן אלא על אכילה ושתיה בלבד אבל אם רחץ או סך או נעל מכין אותו

מכת מרדות”.

דין חולה לגבי יום כיפור

כתוב: ל”ט פרק כהלכתה שבת שמירת בספר השבת את לחלל היא מצווה ואף שמותר “כשם להצלת חיי אדם בכל מקרה שקיימת סכנה או ספק סכנה, כך גם מותר ואף מצווה היא על חולה כזה שיש בו סכנה וספק סכנה לאכול ביום הכיפורים, את להציל כדי היום את עליו לחלל מצווה לכן אבל זה ברגע לחולה סכנה אין אם ואפילו חייו. ומצווה אז מותר גם יאכל, ייתכן שיסתכן אם לא ביום החולה את שמאכילים מקרה בכל לאכול... הכיפורים צריך לשקול אם די לו באכילה או שתיה בשיעורים... או אם צריך להאכילו ולהשקותו כרגיל וכן יש לשקל אם הוא צריך לאכול ולשתות או די

לו בשתייה בלבד.”

יש להדגיש כי בחולה שאין בו סכנה מצווה עליו לצום ולהימנע מאיסור כרת, ואם הוא צריך לקחת תרופות מותר לו לבלוע אותן אבל אסור לו לשתות

מים כדי להקל על הבליעה.

דין חולה הסוכרת

כפי שעלינו לבחון כל חולה באיזו מידה הצום יכול להזיק לו כך הדבר גם לגבי חולה הסוכרת. את חולי הסוכרת ניתן לחלק למספר קבוצות: חולים מאוזנים וחולים לא מאוזנים, חולי סוכרת מטופלים בדיאטה אינסולין. ובזריקות הפה דרך בתרופות בלבד, חולים שאינם מאוזנים וצמים, עשויים להסתכן כפי שראינו ברשימת הסיכונים לעיל. לעמותם חולים

סוכרת מאוזנים יוכלו לצום כפי שנפרט בהמשך.

HBA1C שרמת חולה הינו מאוזן חולה בכלל, נמוכה מ7.5% ואינו סובל מבעיות פעילות הנובעות מסיבוכי הסוכרת. התיבשות טבעית שיכולה לפגוע בתפקוד של הכליות. כל חולה שרמת הקריאטינין בדם היא מעל 1.5 מ”ג%, צום משתייה עלול לגרום לסכנה לכליה ויכול להיגרם מכך סיכון של כל הגוף, ולכן חולי סוכרת עם פגיעה כלייתית גם אם חייבים

בצום מאכילה, חייבים לשתות.

בעבר היה מקובל כי כל חולה סוכרת המטופל באינסולין הוא בגדר חולה שיש בו סכנה ולכן אינסולינים ישנם כיום אך לצום. עליו אסור את מספקים אשר לנטוס כדוגמת חדשים לגוף האינסולין של הבזאלית הצריכה החולה ולכן בצום, הסוכר רמת את ומאזנים סכנה” בו שיש “חולה מגדר יוצא הסוכרתי לגדר “חולה שאין בו סכנה” ואז יש עליו לצום

ביום הכפורים.

לא אחר, אינסולין שמקבל חולה מידה באיזה והוא לא עונה לקריטריונים שקבל לנטוס, )מאחר החובה עליו חלה לנטוס( למתן הבריאות סל ע”מ כיפור יום לקראת בלנטוס לטיפול לעבור למעבר הצפויה הכספית )ההוצאה לצום? שיוכל ללנטוס ולאיזון תחת טיפול זה שהוא גם טוב יותר הקלאסיים באינסולינים מטיפול יותר ופיזיולוגי

הוא בשנת 2007 כ- 450 ש”ח(

שאלה זו הפניתי לרב אפרתי שליט”א אשר העלה כי אליישיב שליט”א אשר פסק אותה בפני הרב יש חובה על האדם להוציא מכספו ע”מ להימנע

מאיסור כרת.

שלפניכם בטבלה הקוראים לנוחות לחולי הרפואיות ההנחיות מתומצתות

הסוכרת:

הערות:

מאוזנים סוכרת לחולי מתייחסות •ההנחיות שאינם )7.5% – מ פחות A1C )המוגלובין קטן )קריאטינין כלייתית ספיקה מאי סובלים ספיקת מאי הסובלים חולים מ”ג%(. מ-1.5

כליות חייבים בשתייה בלבד ולא באכילה.

בעיות להם שאין לחולים מתייחסות •ההנחיות אי כמו אחרות מאוזנות לא רפואיות פעילות

ספיקת לב או תעוקת חזה בלתי מאוזנת וכו’.

•אין ההנחיות מתייחסות לנשים סוכרתיות הרות או לאחר לידה

מאומצת גופנית מפעילות להימנע הצם •על ובלתי שגרתיתי.

יש פרטי מקרה ובכל כלליות הן אלו •הנחיות להיוועץ עם הרופא המטפל.

oheu,n ohghr | d | yWxa, hra,


sWxcForeWord

It’s that time of the year again… Summer vaca-tion is winding down as the evening breeze be-

gins to pick up. Thousands of boxes and suitcases later, our community will be elbow deep in Yom Tov preparations and back-to-school plans, with summer but a sweet memory.

For our members, both the Yom Tov season as well as the back-to-school days present unique chal-lenges. In this expanded issue we are addressing these aspects of our lives from various points of view. We hope you will find the information useful and revealing.

Yom Kippur is certainly high on everyone’s list of concerns. aside from our spiritual preparations, the fasting question must be dealt with responsibly. We all speak to our doctors, reconfigure our pump settings, are extra-vigilant on the days before Yom Kippur, and do everything within our power to be able to fast. Yet, we must remember that ultimately our attempt at fasting is just that – an attempt. If it works out, that’s wonderful. If it doesn’t, that too is ratzon Hashem.

It is very disheartening to have to break the fast on Yom Kippur. We certainly must do everything pos-sible to plan carefully for the holiest day of the year, but for some of us, fasting will still be impossible. If it happens to you, please remember that your obli-gation is to try and do your best. The outcome is not in your hands, and you will not be held accountable for it, so long as you tried.

There is a heartwarming chassidish vort that can give us chizuk in this situation: Chazal said, “When a person desires to fulfill a mitzvah but is unable to do it, it is counted in Heaven as if he fulfilled it.” When a person fulfills a mitzvah, there is always

a possibility that the mitzvah will be deficient in some way. perhaps his intentions were not as pure, or his fervor was lacking. However, when he desires to do a mitzvah but is unable to do it in the end, it is counted as a complete, wholesome mitzvah. It may end up being a far more elevated mitzvah than he could have ever done! So if you must break your fast, remember that it is counted in Heaven as if you fasted. This may even turn out to be your most elevated Yom Kippur ever!

The other seasonal issue affecting us at this time of the year is preparing our children with type 1 diabetes for a new school year. a new year means a new staff, an older child, and other changes. al-though we at FWD are certainly the first to say that children with type 1 diabetes are just like all other children, and their lives should be free of restric-tions, we wish to remind parents of the importance of careful planning. our children need a supportive environment in school. Sometimes, all it takes is for parents to contact staff members in advance and make the necessary introductions. Some of the tips in this issue of Going ForWarD will hope-fully be useful to parents as they try to make their children’s new surroundings safe and supportive. We’d appreciate hearing about your experiences. By sharing, you can help other parents who are facing the same challenges.

We wish our members and all of Klal Yisroel a sweet year full of good health and nachas. May this finally be the year of the Geulah Sheleima, בב“א.

Rabbi Hirsch Meisels


revisitingyom kippur Answering

your questionsheArd over the phone

Much has already been published in the pages of Going ForWard re-garding the details of blood sugar control before, during, and after the Yom Kippur fast. but there’s always more to add on the topic… this year, let’s examine some of the questions we fielded from our members.

rrring… rrring….

Mrs. G.“rabbi Meisels? thank you so much for giving me a few minutes of your time. i’m really calling for my husband, who was diagnosed with type 2 diabetes three years ago. You know, fasting was always difficult for him so i was wonder-ing if there are any specific foods he should be eating or avoiding on erev Yom Kippur in order to make things easier. One thing i know for

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sure is that he has to drink like a camel! sixteen glasses of water at least…”

Rabbi Meisels“it’s interesting that you’re men-tioning the water because many people have that misconcep-tion. the exact opposite is ac-tually true: drinking too much water can trigger dehydration as the body rapidly eliminates the overload of liquid. i would recommend a much more mod-erate (and easier!) approach: starting several days before the fast, make sure to drink adequate amounts (not more than 8 cups) of water daily. in this way, when Yom Kippur arrives, your body will be optimally hydrated and you have a much better chance of retaining the liquid.”

Mrs. G.“really? hmmm… this may be helpful for everybody in our family, not just my husband. but i really am worried about him. You know, last Yom Kippur he felt positively awful. he came home from shul in middle of the day, feeling extremely dizzy and weak. and the funny thing is that he had been especially careful to eat plenty before the fast, so we really don’t know what we can possibly do this year to avoid a repeat performance.”

Rabbi Meisels“What kind of foods did he load up on before the fast?”

Mrs. G.“Well… no fish at the seudas hamafsekes, of course, so he must have eaten plenty of chal-lah, plus my delicious potato kugel, farfel and carrots, and my famous stuffed chicken. and probably more than one portion of whatever was for dessert… Oh, and lots of grapes, of course! We heard those are very helpful prior to a fast.”

Rabbi Meisels“Oy vey! Let me explain what happens on a fast day to people with type 2 diabetes, and any-body else who is insulin resistant. after several hours without food, their bodies actually become more sensitive to insulin and this sudden change triggers many uncomfortable symptoms. they will lose large quantities of water and minerals and will probably feel dizzy, faint, and just down-right lousy. What you want to do is avoid large amounts of carbo-hydrates before the fast. Focus on protein-rich foods prior to Yom Kippur so that your husband won’t undergo a drastic change in insulin resistance as the fast day wears on. Cut the challah, limit the starchy side dishes, and definitely skip the grapes!”

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Mrs. G“i can’t believe what you’re telling me! We’ve been doing it all wrong! but my cousin’s neighbor’s son has type 1 diabetes and is not insulin resistant. are you saying that he could eat large amounts of carbs before Yom Kip-pur?”

rabbi Meisels “i actually wouldn’t recom-mend that anybody- with or without diabe-tes- fill up on carbohydrates before a fast. but people who use insulin have an additional concern: they need to accurately count all the carbohydrates that they will be consum-ing, and cover with appropriate amounts of insulin. When dealing with large amounts of carbs, it’s easy to make mistakes and take too much insulin. the last thing anybody would want is to end up with a low blood sugar and then need to eat at the very beginning of Yom Kippur. so my advice to people with type 1 is: Limit the carbs before the fast and count those carbohydrates accurately.”

Mrs. G“this conversation has been more enlighten-ing than i could have imagined. i am eager to implement the changes you mentioned and look forward to a much easier fasting experi-ence!”

rrringgg… rrrringgg…

Jeff“rabbi? i wanted to share this amazing idea i had. You know, ever since i got my insulin pump in december, i’ve been looking forward to a much easier Yom Kippur fast. and now i had this incredible brainstorm. i mean, i don’t know why nobody thought of this before! it’s just…”

Rabbi Meisels“nu, Jeff, what is it already?!”

Jeff“Okay, listen. suppose i get a low blood sugar on Yom Kippur, right? Well, on the pump it’s no problem. all i gotta do is suspend the insulin delivery! no more insulin, no more low!”

Rabbi Meisels“i hate to disappoint you, Jeff… but, no way! the truth is, you’re not the first person to think of this but i want you to know that it’s dangerous. suspending the pump won’t raise your blood sugars

quickly enough, and the halacha is clear: if your blood sugars reach a predetermined low point on Yom Kippur then you have to eat. Pe-riod! and, by the way, think what will happen if you suspend your insulin pump for a while. You’ll be stuck with super high blood sugars after the fast, which is a time when glucose control is difficult enough to begin with. so there’s no get-ting away with it… be careful, be cautious, but keep brainstorming! You never know what really great ideas you’ll come up with next!”

Wishing all our readers an easy and meaningful fast! n

Mazel Tov To…

Member and his Kallah upon their engagement and marriage 2397 2909

Members and their wives upon the birth of their baby boys2 105

Members and their husbands upon the birth of their babyboy 652 2282 2417 2949girl 471 733

Members and their parents upon their Bar Mitzvah572 2827 2928


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