Statement Regarding Patients with Type 1 Diabetes Mellitus Fasting on Yom Kippur

This statement is the opinion of the endocrinologists whose names appear below. It is based on several
articles published in peer-reviewed journals (see references below) and our cumulative experience in
treating patients with type 1 diabetes. This statement addresses only type 1 patients and NOT patients
with type 2 diabetes who are being treated with insulin (although many of the ideas expressed below
would apply to them also). It also does NOT include the pregnant T1DM patient, who should not fast.
Additionally, this statement is not meant to preclude directing any questions having to do with religious
observance to a competent Rabbi.

BACKGROUND INFORMATION

Allowing a patient with type 1 diabetes mellitus (T1DM) to fast on Yom Kippur must take into account
the unique risk factors of hypoglycemia and diabetic ketoacidosis. The other potential considerations,
including dehydration, hypotension, and the like, while important, are not unique to T1DM. The same
considerations that a physician would make with all patients would apply equally to T1DM patients.
(The one exception is that any diabetic patient (not just type 1) whose glucose goes high will likely
become dehydrated faster than a non-diabetic. This consideration would, however, be dealt with by the
requirement to deal with any sugar above 250 mg%, as mentioned below.) This statement therefore
addresses the unique considerations relevant to the blood glucose.

Patients with T1DM are at increased risk of suffering from the above mentioned complications.
However we are aware of the extreme importance of the Yom Kippur fast to many of our patients and
believe that in certain circumstances a specific patient can be given permission to fast by his personal
diabetes specialist who knows the patient’s history, and assesses his ability to fast on that special day,
guided by education, specific instructions, and intensive monitoring. These specific instructions must
include reductions in insulin dose, minimum frequency of blood glucose monitoring, and absolute
guidelines when to terminate the fast if the blood glucose goes above or below a predefined (and
individually determined) range.

HYPOGLYCEMIA: The development of hypoglycemia occurs when the T1DM patient takes more insulin
than he needs to maintain a reasonable blood glucose while fasting. Every person, whether diabetic or
not, needs some insulin even during a 25 hour fast. The T1DM patient who uses multiple daily injections
should take only “basal” insulin (glargine or detemir), but no rapid acting insulin after the “seuda
hamafsekes ” (the meal before the fast begins). Published guidelines offer suggestions on how much to

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reduce the basal insulin prior to the fast, though individual management by the treating endocrinologist
must be provided (which would also include those patients on NPH as their basal insulin). With
appropriate reduction in basal insulin, the blood glucose can be safely maintained between the normal
range and mild elevation, which would not ultimately affect the long-term outcome of the patient’s
health. The patient should monitor his fingerstick blood glucose before going to bed on the night of
Yom Kippur and upon arising on the morning of Yom Kippur, and then every 2-4 hours (as a minimum;
some patients may need to check more often). The patient should be given instructions that if the blood
glucose falls below a specific number (generally in the 70-90 mg% range) OR the patient has symptoms
which could represent hypoglycemia (keeping in mind that fasting itself can produce symptoms, like
headaches, similar to those of hypoglycemia), additional readings should be done. Finally, the patient
should be given instructions to terminate the fast if the blood glucose falls below a specific blood
glucose (65-80 mg% depending on the patient) even without symptoms OR is below a specific glucose
(80-90 mg% depending on the patient) with clear hypoglycemia symptoms.

A patient on the insulin pump would follow these same general guidelines except that, since he is using
a short acting insulin, the “basal” infusion needs to be reduced by a lesser amount. There are published
guidelines for how much to reduce the basal infusion rate (see references).

DIABETIC KETOACIDOSIS (DKA): Any T1DM whose diabetes has NOT been adequately controlled prior to
Yom Kippur, with blood glucoses consistently over 250 mg/dl, should NOT be permitted to fast. In
addition if the T1DM patient presents with ANY signs of fever or infection prior to Yom Kippur, fasting
should not be permitted (see below). During the fast, if the blood glucose rises above 250 mg%, we
recommend a small supplement of rapid acting insulin, with a repeat blood glucose 1-2 hours later. If
the glucose continues to rise the patient should immediately break his fast, drink plenty of liquids, and
take additional insulin. The likelihood of DKA developing under these circumstances is miniscule. All
patients who develop DKA do so due to the coexistence of an infection with uncontrolled diabetes OR
due to ignoring a rising blood glucose. A patient fasting on Yom Kippur, who had no signs of fever or an
infection prior to the fast, and who takes additional insulin and adequate liquids during the fast if the
blood glucose stays above 250 mg% would NOT be at risk for developing DKA.

While we recognize that medicine is not an exact science, and that there often are differing opinions on
treating most medical conditions, we would respectfully submit that the opinions presented in this
statement reflect the published literature, as well as that of respected diabetes specialists
internationally, all of whom have personally advised T1DM patients on how to safely fast on Yom

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Kippur. We also recognize that Jewish law states that when it comes to a patient’s health, the opinion
of two doctors who say a patient should not fast can override 100 doctors who say he can fast. We
would suggest that this applies to an INDIVIDUAL patient, not to establishing overall policy and
guidelines. We would wholeheartedly agree that the INDIVIDUAL patient with T1DM, who is known
to his personal diabetes specialist, should rely only on his personal physician, and not on general
guidelines or on his own judgement, when it comes to deciding whether or not to fast on Yom Kippur.

RECOMMENDATION

We recommend that a T1DM patient should be allowed to fast on Yom Kippur PROVIDED he or she
obtains from their personal endocrinologist 3 things: 1) the APPROVAL to fast, 2) GUIDANCE on
adjusting the insulin dose, and 3) GUIDELINES directing the patient how often to check the blood
glucose and under which circumstances the fast must be terminated. Furthermore, we strongly advise
that the personal endocrinologist, prior to approving the patient to fast, take into account not only
knowledge of the particular patient’s glycemia history, but equally importantly the patient’s history of
compliance with medical advice (especially in adolescents).

Respectfully submitted:

Martin M. Grajower, MD, FACP, FACE

Assistant Clinical Professor
Department of Medicine
Division of Endocrinology
Albert Einstein College of Medicine
Bronx, NY
corresponding author: Grajower@MSN.com

David Zangen MD
Division Of Pediatric Endocrinology
Head, Pediatric Endocrine & Juvenile Diabetes Center
Hadassah Mt. Scopus
Hadassah-Hebrew University Medical Center
Jerusalem, Israel

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Henry Anhalt, DO, FAAP, FACE, FACOP Irl B. Hirsch, MD
Pediatric and Adolescent Diabetes & Endocrinology Professor of Medicine
Hackensack, NJ University of Washington Medical Center
Seattle, WA
Norman Fleischer, MD, FACP
Jeanne and Jacob Barkey Professor of Medicine Elka Jacobson-Dickman, MD
Director, Division of Endocrinology Assistant Professor, Pediatrics
Co-Director, Diabetes Research Center Pediatric Endocrinology
Albert Einstein College of Medicine State University of New York
Bronx, NY Downstate Medical Center
Brooklyn, NY
David Gillis, MD
Head, Pediatric Endocrinology Service Lois Jovanovic, MD, MACE
Hadassah-Hebrew University Medical Center Director & Chief Scientific Officer
Jerusalem, Israel Sansum Medical Research Institute
Clinical Professor of Medicine
Benjamin Glaser, MD University of Southern California
Professor of Endocrinology Los Angeles, CA
Director, Endocrinology and Metabolism Service
Hadassah-Hebrew University Medical Center Dan Lender, MD
Jerusalem, Israel Director of the Clinical Diabetes Research
Hadassah University Hospital, Ein-Karem
Robin Goland, MD Jerusalem, Israel
Co-Director, Naomi Berrie Diabetes Center
Professor of Clinical Medicine and Pediatrics Derek LeRoith, MD, PhD, FACP
Columbia University Medical Center Chief of the Division of
New York, NY Endocrinology, Diabetes and Bone Diseases
Mt. Sinai School of Medicine
Joel Goldman, MD, FACP, FACE New York, NY
Director of Endocrinology
Brookdale University Hosp. and Medical Center Noel Maclaren, MD
Associate Professor of Clinical Medicine State Director, Cornell Juvenile Diabetes Program
University of New York Professor of Pediatrics
Brooklyn, NY Weill Cornell College of Medicine
New York, NY
Michael Haller, MD, MS-CI
Assistant Professor Lyle Mitzner, MD
Pediatric Endocrinology Instructor in Medicine
University of Florida Harvard Medical School
Gainesville, FL Staff Physician, Joslin Diabetes Center
Boston, MA
Kevan Herold, MD
Professor of Immunobiology and Internal Medicine
Yale University School of Medicine
New Haven, CT

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Chayim Y. Newmark, MD, FAAP1 Roy E. Weiss, MD, PhD
Assistant Professor of Pediatrics Rabbi Morris I. Esformes Professor
University of Medicine and Dentistry, New Jersey Chairman, Department of Medicine
Pediatric Endocrinology Chief, Section of Adult and Pediatric Endocrinology,
Saint Barnabas Medical Center Diabetes and Metabolism
Livingston, NJ The University of Chicago
Chicago, IL
Mark J Niven, MD
Director of Endocrine and Diabetes Unit Stuart Weiss, MD
incorporating The Bildirici Center Assistant Clinical Professor
for Diabetes Care and Research New York University School of Medicine
Deputy Director of Internal Medicine B New York, NY
Laniado Hospital
Kiryat Sanz, Netanya, Israel Don Zwickler, MD
Chief of Division of Endocrinology
Robert Rapaport, MD Good Samaritan Hospital
Professor of Pediatrics Suffern, NY
Emma Elizabeth Sullivan Professor
of Pediatric Endocrinology and Diabetes
Director, Division of Pediatric Endocrinology and
Diabetes
Mt. Sinai School of Medicine
New York, NY

Itamar Raz, MD
Head Diabetes Unit
Department of Medicine
Hadassah University Hospital
Ein-Karem, Jerusalem
President of the Israel Diabetes Association

Desmond A. Schatz, MD
Professor of Pediatrics
Medical Director, Diabetes Center
University of Florida
Gainesville, FL

Mark A. Sperling, MD
Professor of Pediatrics
University of Pittsburgh
Pittsburgh, PA
Editor-in-Chief, Pediatric Diabetes

1
Dr. Newmark passed away suddenly on July 14, 2010, after signing
this statement.

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References:

1. Management of Diabetes Mellitus on Yom Kippur and Other Jewish Fast Days. Grajower, MM.
Endocrine Practice, 14: 305-311, 2008
2. Type 1 Diabetes and Prolonged Fasting. Reiter J, Wexler ID, Shehadeh N, Tzur A, Zangen D.
Diabetic Medicine, 24: 436-439, 2007.
3. Fasting and insulin glargine in individuals with type 1 diabetes. Mucha GT, Merkel S, Thomas W,
Bantle JP. Diabetes Care 27:1209-1210, 2004
4. Friends with Diabetes guidelines on pump management:
http://www.friendswithdiabetes.org/files/pdf/tishrei5769.pdf (Page 21)

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