Inside - Friends With · PDF fileI knew about simple and complex carbs but learning about GI...

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4488 Friends With Diabetes • Rabbi Hirsch Meisels

31 Herrick Ave. • Spring Valley, NY 10977(845) 352-7532 • Fax (845) 573-9276

[email protected]

F.W.D. is under the rabbinical supervision of Rabbi M. M. Weismandl shlit”a of Nitra – Monsey. Endorsed by many other leading Rabbonim.

The information in this newsletter is meant to be used in conjunction with, and under the guidance of, your health care pro-fessional. It is NOT meant to diagnose or treat medical conditions, nor as advice or prescriptions. It is provided for education-

al purposes only. In the event that you use the information without your doctor’s approval, you are prescribing for yourself,which is your constitutional right, but F.W.D. and the authors of this newsletter assume no responsibility. We strongly advise

that you inform your doctor of any changes you wish to make.

Please consult your physician for medical questions, and your Rav (Rabbi) for halachic (Jewish law) decisions.

Likewise FWD does not take responsibility on the kashrus or quality of its advertisers.

© Friends With Diabetes Tishrei 5764 • Fall ’03

No reprints allowed without prior permission.

Inside ...g DROP US A FRIENDLY LINE

g FOREWORD

g FACING FORWARD — What’s New at FWD?

g YOM TOV GUIDE

ROSH HASHANAHSimonim

YOM KIPPURTo Fast or Not to FastGuidelines for FastingOur Gedolim Showed the WayA TefillaAmounts for Pachos M’kshiurAfter the Fast

g FINE TUNING YOUR BASAL RATES

g SHABBOS SUGARSA Shabbos Meal

g IN CONTROLMaking your PDA your Personal Diabetes AssistanceFriend to Friend

g SWEET SUCCESSCarb Factors Made Easy

g HALACHA TIDBITS

Friends With Diabetesoheu,n ohghr

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To the Moderator of FWD email discussion group:

I just joined this group after finding your website. I’ve been a type 2 dia-betic for a few years now. I read the three supplements (Pesach, Tishrei,Winter) from your site, from cover to cover and found them packed withnew information.

I knew about simple and complex carbs but learning about GI and GLand tons of other stuff was a real eye opener, yasher koach! You gaveme such motivation that I wentback to a serious diet, went back tomy diabetes diet expert and startedlosing weight and doing exerciseagain. After two months, my bloodsugars have lowered and stabilized.

I was eating 8 rice cakes a day until Iread your comments on them. Istopped.

Kol HaKavod to FWD.

Mordechai from Yerushaleyim

k

To FWD staff:

Thank You so very very much for the mostinformative Shavous issue we justreceived. We made the cheese cake recipeyou provided, and enjoyed a delicious yetlow carb Yom Tov! Thanks for having us inmind. Even though it’s just a little pam-phlet, we enjoy them immensely!

M.F.

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Dear Rabbi Meisels:

We received the latest publication GoingForWarD a few days ago and it is truly a mas-terpiece! Although we have only glanced at itat this point, we see that there is a wealth ofinformation in it. The beautiful format and col-orful cover also add so much to it. Your YomKippur issue enabled our daughter to fast wellprepared. And the Pesach issue led us step bystep through the seder night with good results.None of this information is addressed anywhereelse. Reading through your publications has notonly been much more helpful than anything elsewe’ve read, they have actually made adhering to‘the plan’ possible. Thanks loads!

D.P.

To the devoted Family Meisels:

A thoughtful act or a kind word may pass in a moment, but the warmthand care behind it stay in the heart forever! How can I express my sin-cere feelings of gratitude for all the time you spent tending our needs.No matter when it was you were always there to help us. Your unbe-lievable kindness and devotion have been constantly appreciated.

F.G.

To Rabbi and Mrs. Meisels:

My pen doesn’t have enough ink to express my thanks to you. Whatcouldn’t be done in eleven years was done in one Shabbos! E.R.

D R O P U S A F R I E N D L Y L I N E

2F R I E N D S W I T H D I A B E T E S

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To the Meisels;

The words thank you cannot describe our cuyv ,rfv that we feel

towards you for the recent Shabbos our daughter attended. Since she

was diagnosed six years ago, she has felt insecure about being away

from us and she never spent the night away, let alone an entire

Shabbos!

I was nervous about her reaction and if she would want to go at all.

In spite of her anxiety, as the Shabbos was getting closer I could tell

she was starting to get excited. She had never met a single girl with

diabetes, and now she was going to spend time with so many frum

girls dealing with the same issues. The isolation of always being the

only one is exceptionally hard for anyone to handle.

Erev Shabbos came and with a big smile she waved good-bye, and vWc

she had a bigger smile on Motzei Shabbos when we picked her up.

She could not stop talking about all the wonderful girls she met, and

all the fabulous things she did, and the fantastic gifts that were hers

to keep! Being able to check her blood sugar openly and laugh with

friends about being too high to eat was a very welcome change. What

a chesed to give these girls that feeling of belonging to a group.

If I had to sum up what my daughter gained from this special

Shabbos, I would say it was a wonderful opportunity for a self-con-

scious, shy girl to open up and enjoy the company of so many sweet

and friendly girls. Sleep-away camp is starting to sound like a possi-

bility. The knowledge from the fun workshops and tips the girls shared

with each other were great. The most important change was her

expressing interest in going on the pump whereas in the past she was

very reluctant. The self confidence she gained from being away on her

own gives me the most nachas. She takes more of an interest in tak-

ing care of herself. She also insisted on telling some close family

members about her diabetes, so she can feel more comfortable when

they are around.

There are always more obstacles to overcome but this one Shabbos

was a giant leap for her. Please pass this letter on to all the wonder-

ful people who helped you arrange this successful Shabbos so they

can see that their efforts were very much appreciated and brought vWc

the desired results.

Thank you again, and looking ForWarD to next year’s Shabbos.

Mrs. S.

If a person’s life is endangered, is he allowed to escapea pursuer on Shabbos? States the midrash in parshasMasai: Yes! Escape would be permissible, even on

Shabbos. And this law is derived from the actions of ourvery forefathers, Jewish leaders of all generations. KingDavid fled from King Shaul on Shabbos; MosheRabbeinu departed from Egypt on Shabbos whenPharaoh sought to kill him; and when Yaacov escapeddeath at the hands of his brother Eisav, it was also on aShabbos. Thus, the very cream of klal yisroel set animportant precedent. A most obvious question presents itself. Why did theribono shel olam arrange events so that our great ances-tors would be forced to flee for their lives on our holiestday, Shabbos? After all, Hashem could do anything.There must be a reason why He coordinated their escapeto coincide with Shabbos.Perhaps a very powerful lesson was being taught for Jewsof all times and all situations. If an individual is everrequired to desecrate the Shabbos because of pikuachnefesh (in order to save his life), let him do so with an easyand confident heart. “Maasei Avos Siman Labanim”, thedeeds of our fathers set a precedent for us children. And inthis case, no lesser role models than our holy ancestors, ourforefathers, kings and leaders, have set the example! In this publication, the issue of fasting (and not fasting)on Yom Kippur is discussed at great length. Before youeven begin tackling the details, remember the abovemidrash. One who is not allowed to fast on Yom Kippuris following in the footsteps of our greatest leaders!

Would we desire to be holier than Moshe Rabbeinu? Hefulfilled his duty as a Jew by escaping an enemy onShabbos. Sometimes, the duty of a Jew is to eat on YomKippur. As Rav Chaim Brisker once expressed himself, “A mohelnever felt annoyance at having to perform a circumcisionon Shabbos. He is happy to do what the Torah demands,and those who are required to eat on Yom Kippur musthave the same perspective.” May we merit the clarity of vision to fulfill our Torahobligations with simcha, with true joy, in all situations.Whenever we merit releasing another FWD publication,our first reaction when seeing the completed book, isinvariably one of awed amazement. How could we haveproduced this finished product, we wonder, with so littletime; such inadequate financial resources; and such a lim-ited staff, all of whom carry many responsibilities asidefrom their work for Friends With Diabetes? And so we are compelled to declare: To the One Whosends us all those good messengers, every timelydonation, each unexpected change in schedulethat allows us to submit another article to thegraphic designer before the deadline… Tothe One Who gave us diabetes, andthen helps us, every day, to riseabove and beyond it…Thank you, Ribono ShelOlam. Thank you, thankyou, Hashem.

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F O R E W O R D

,Whavzgc

Wishing you all a vch,f

vcuy vnh,ju

Rabbi Hirsch MeiselsFriends With Diabetes

oheu,n ohghr

We would like to extend our deep appreciation to the following medicalprofessionals who have surpassed all obligations in their wonderfulshow of support for Friends With Diabetes:

— To Dr. Henry Anhalt of Maimonides Medical Center, who personi-fies the essence of chesed and selfless giving. Special mention to hisassociate Dr. Svetlana Ten.

— Dr. Noel K. Maclaren of Weill Medical College/ Cornell Universityis available for us 24 hours, always in his warm and thoughtfulway.

— To Dr. Robert Rappaport and all his associates at Mount SinaiMedical Center who devote so much time and effort to all theirpatients.

— To Dr. Oded Langer and Dr. Barak Rosen from OB-Gyn at St.Lukes Roosevelt Hosp. for sharing their expertise with FWD women.

— Dr. Don Zwickler, you always make me feel like a close friend. It isjust interesting that all your other patients feel the same way! Specialmention also to associates Deborah Raice and Barry Lipshitz.

Our gratitude to the following individuals/corporations fortheir support now and always:

— To Audrey Finkelstein, Vice President of Marketing/Clinical Affairs for Animas Corp., thank you for treat-ing FWD like family!

— To Wendy Donohue from FreeStyle for donating aPDA and the Freestyle tracker module for our PDAsoftware review.

— To Diana Filipiak from SimpleChoice, who provided uswith sample materials free of charge.

— To the Friedmans of Better Health for their multi-faceted support. You are always there for us financial-ly, emotionally, or in whatever way needed.

— Thanks to Shelley Goldberg & Cathy Messinger from B-D.

— Thanks to entire wonderful staff at Dynagrafik DesignStudio, for their patience in helping us meet our tight deadlines!

— “Thank you” will never be adequate for my father shlit”a, who is this organization’s first and greatest fan, and continues todo more for us than I can ever repay; and to my wife, who selflessly donates her energy, time, and, sometimes… even herhusband, for the success and benefit of all. May they both merit joy and nachas from our own family and from the entireFWD family for whom they sacrifice so much! In the names of all Friends With Diabetes, RHM-FWD

F R I E N D S W I T H D I A B E T E S

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F A C I N G F O R W A R D


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SHEVAT 5763-JANUARY ‘03

Friends With Diabetes CelebratesMemorable Shabbaton

This past Shabbos, sixteenteenaged girls with diabetes

celebrated a unique Shabbos ofunity and friendship in Monsey,NY. The theme of the Shabboswas splendid Air”weighs”, and thespeeches focused on ‘flying high’,making the most of one’s oppor-tunities in life.

The entire Shabbos was oneSplendid Journey, with an excel-lent ‘flight crew’ including a R.N.,C.D.E. and a Registered Dieticianon board. Rabbi Pinchos Jung, thedynamic guest speaker, elaboratedon the middah of hakoras hatov.The professional workshops andhands-on presentations opened upnew areas of discussion and educa-tion.

Although hailing from diversegeographical areas and back-grounds, the girls had bonded likeone big happy family by the endof Shabbos. The many volunteers

tremendously enhanced theevent’s organization and success.

One 14 yr old said to her motherthat this was her happiest Shabbosin her life!

The grand Shabbos finished witha bang in the form of a geshamakeMelava malkah with inspirationalgames, and swimming in anindoor pool. The girls parted withemotional goodbyes, promising tokeep in touch.

(Reprinted fromYated Ne’eman, Shevat 5763 / Jan. 24

‘03, under “Community News”.)

Friends With Diabetes Meetto Share ChizukIt was a beautiful spring evening

when some 20 women droppedhectic and demanding schedulesto update, uplift, and upgradetheir diabetes self-care. In additionto the invaluable benefits of min-gling with old friends and meetingnew ones, participants were treat-ed to a most informative presenta-

4

What’s New at F.W.D.?Available...Think back: Have you missed a Going ForWarD?PESACH (Yiddish and English)• A thorough guide to the Kazaisim Matzah, Four

Cups, and many Pesach tips, plus;• Exercise• Glycemic Load• Halacha Tidbits and more.

WINTER (Yiddish and English)This issue is chock full of information, including:• Chanukah: Calculating carbs for homemade

recipes• Tu B’Shevat: Effective Carb Factors, and the

Glycemic Index• Purim: Diabetes and Alcohol, and more• Controlling morning blood sugars and some

breakfast tips• Choosing and using a food scale

SHAVUOS 5763 (English)• All you ever wanted to know about cheesecake:

Why we eat it, how to make it, what’s in it, andshould the protein be covered with insulin?

FILES TO DOWNLOAD:SUMMER TIPS (Yiddish)• Exercise during summer• Avoiding dehydration• Storing diabetes supplies in summer

DIABETES & SHABBOS• We have written a comprehensive 5-page Hebrew

article of frequently asked questions about dia-betes on Shabbos. This can be presented to a Ravwho does not possess medical knowledge, to helphim understand the concept of diabetes, so that heshould be able to give psokim on this topic. Feelfree to contact us for a copy.

GUIDE FOR TEACHERS (Yiddish)• As the Cheder year began, we received an over-

whelming number of requests to educate themelamdim/teachers. In response we have trans-lated a page from the CWD website to Yiddish.

ALL OUR PUBLICATIONS ARE AVAILABE TODOWNLOAD FROM OUR WEBSITE

JOIN• Our “Friends With Diabetes” discussion list at

http://groups.yahoo.com/group/FriendsWithDiabetes• Our “Kosher Low-Carb” discussion list at

http://groups.yahoo.com/group/Kosher-Low-Carb• Our “Jewish Insulin Pumpers” discussion list at

http://groups.yahoo.com/group/JewishInsulinPumpers

www.FriendsWithDiabetes.orgOur new and improved website is now up and running! Check out someof these fabulous features:

FWD publications & many other useful articles available to download (inPDF format)Links to many other wonderful websitesList of recommended books, plus you can even buy these books fromAmazon.com with just one easy click! A margin of the profits of anybooks sold through our website will go to FWD.Links to our email discussion listsLink to a site that will accept your credit card for donations to FWD.

— www.KosherLowCarb.org currently under construction —

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tion by a leading medical professional.The evening was topped off by a live-ly question and answer session, somewarm insights from Rabbi Meisels,and a salad bar complete with nutri-tion facts. It was late by the time thewomen left for their respective homesthroughout New York and NewJersey, but each enthusiastically agreedthat even a sink full of dirty dishes wasa small price to pay for this wonderfulexperience!

(Reprinted from YatedNe’eman, Tammuz/July 5763,

under “Health Bits”.)

Iwould like to pay trib-ute to a one-of-a-kind

doctor, teacher, rolemodel. It is a long over-due and much understat-ed “Thank You” toRabbi Meisels and fami-ly, director of the won-derful organization,“Friends With Diabetes”.Rabbi Meisels is nottechnically a health pro-fessional, but health ishis occupation and sav-ing lives is his profession.He literally devotes hisdays and nights to thisAvodas Hakodash. He isconstantly instructing,advising, and encourag-ing Jewish families withdiabetes. From his i n fo rma t ion -pa cked publications, to the excit-ing get-togethers, andShabbosim that he orga-nizes, he is always therefor us. He taught us thatdiabetes won’t stop us.It’ll make us goForWarD. Diabeteswon’t embitterus, it will onlymake our livessweeter, and ithas!

“Medicine is a science, caring is anart” - to a family who specializes inboth medicine and caring, ThankYou! May the Ultimate Scientist andMaster Artist grant you every sweetBracha.

From all your friends with D, aimingfor BGs in the middle!

(Reprinted from the Yiddishe HomeShevat/Jan. 5763,

under “Appreciation Mailbox”)

5

P R E S S R E L E A S E :

People with dia-betes, who learn toproperly managetheir condition, canlead a normal life.Thanks to a won-derful organizationcalled Friends withDiabetes, the taskof managing this

condition has become easier than ever.

FWD has compiled a wonderful Pesach handbookespecially for diabetics, detailing many helpfulissues regarding the sedorim, the exact shiurim ofmatzah, and how much carbohydrates the Pesachstaples contain. The issue of Arba Kosos and glu-cose management is also discussed at length,including recommended wines and eating patterns.The publication also contains diabetes-friendlyrecipes and many helpful tips.

The renowned Pesach expert Rabbi AvrohomBlumenkrantz, writes in his annual Pesach digest,“The following information was taken fromGoing ForWarD (Friends With Diabetes, a veryimportant magazine for diabetics) Edited byRabbi Hirsch Meisels shlit”a. Themagazine appears 3 to 4 times ayear and is a must for anydiabetic person toread.”

Friends With DiabetesPublishing Vitalinformation for Pesach(First printed in Yated Ne’eman,14 Nisan 5763 - Apr. 16 ‘03,under “Health bits”.)

Living Openly WithDiabetes Reprinted from the

Jewish Health Forum Magazine

Young Hirsch Meisels had a secret. Thesecret made him feel different from theother boys in his class, more wary andwatchful. It also caused him an enormousamount of stress, way more than anyeight-year-old should have to endure.When Hirsch was five years old, he sud-denly came down with a severe virus andhigh fever. Recovering from his illness, hebegan experiencing some unusual symp-toms and was later diagnosed withDiabetes. He wound up staying in thehospital for two weeks to rid his body ofglucose and began receiving insulin shots,standard treatment for Type 1 Diabetes inthose days.The treatment of, and the attitude towardDiabetes have certainly changed sincethen. Over the past 25 years, dramaticadvances have taken place in how physi-cians treat Diabetes. Some people nolonger feel pressured to keep their illnessa secret, partly thanks to Rabbi HirschMeisels himself. Rabbi Meisels, a Monseyresident, is the executive director ofJewish “Friends With Diabetes”, aDiabetes support group, which encour-ages its members not to hide their illness.About the treatment he underwent as achild, Rabbi Meisels has this to say, “Wewere living in the dark back then. We did-n’t have blood sugar meters to regulateglucose levels, which can fluctuate fromminute to minute. The only thing weknew in those days was to stay away fromsugar and eat on schedule. There was aconstant fear of passing out, and futurecomplications were something to beexpected. But now that we have the toolsand education (to control Diabetes) weno longer fear those complications,because we can iy”h eliminate them.”When Rabbi Meisels was growing up, hewas told to stay away from sugar, because,“That’s all we knew,” he said. “My moth-er made Challah without sugar, and shemade Diabetic cakes. We were trying todo our best. Now, my wife makes Challah‘with’ sugar.” He noted that over the past

(cont. on page 9)



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From A ProfessionalPerspective:Impressions of the Boys’Melavah Malkah, 5763

Rabbi,I just wanted to take a minute to letyou know what an incredible and spe-cial group of people you have atJewish Friends with Diabetes. I washonored and privileged to be a part ofyour group for the evening. Yourdevotion to the kids and to ensuringthat they have the proper tools andknowledge to control their diabetes istruly remarkable and inspiring. Thelevel of education that your boys dis-played is nothing short of amazing! Ihave attended diabetes support groupsall over the metro New York City areaand have never found a group ofadults - let along teenagers - who areso on top of managing their diabetes.This is an obvious testament to yourlevel of caring and concern. You must know that the work you dowill pay great rewards! Years fromnow, these boys will remember youand thank you for inspiring them tolive life to the fullest and to care fortheir bodies as if they were a HolyTemple. Thank you for all your dedi-cation and work. I would also like to congratulate youon the new publication. It will onlycontinue and expand the great workyou are already doing!

Sincerely,Jim Berkebile Territory Manager, Animas Corp.

Rabbi Meisels:I must tell you that the experiencewith your group was a life changingone for me. I have been working withteenagers for well over 15 years and Ihave never met a group quite likeyours. Your work has ignited a pas-sion for good diabetes self care; yourown passion to thrive with diabeteshas spread to your group. I wasamazed at how hungry for informa-tion the individuals in the group were.I felt like we could have stayed therefor several more hours just talkingwith them. Each and every one ofthem wanted to know more, and theirhunger for knowledge was clearly sothat they could make better decisionsabout their own self-management. Itwas also clear how important thegroup itself is to each of them. Thegroup is clearly a safe haven for them. In closing, I firmly believe that theworld needs more people like you tomake living with this condition ablessing.I must tell you that each time I checkmy sugar, I now think of it as a mitz-vah. Thank you for this! Respectfully,Scott ScolnickRegional Manager, Animas Corp.

Reflections on the Girls’Shabbos 5763:

Dear Rabbi,It was with great pleasure that I partici-pated in the Shabbaton with Rabbi andReb. Meisels and group, on January 3and 4, 2003. As a Registered Dietitianwith a background in DiabetesEducation and Insulin Pump Therapy, I

eagerly anticipated meeting and sharingtime with the girls (ages 12-15) whowould attend. I arrived with our nurse(a certified diabetes educator) at 1 PMand the guests started arriving by 3PM. It was snowing heavily so manytravel plans needed adjustment, but notone girl missed the weekend due toweather! We gathered, some more shythan others, and the warm atmosphereindoors quickly melted any reservationpeople may have had about having agood time together. We shared mealsand snacks while discussing the carbo-hydrate content of specific dishes, howeach girl’s blood sugar reacted and howthey managed their own blood sugarreadings. Approximately 10 of the 15girls wore insulin pumps and otherswere on injections. Blood sugars werechecked regularly, highs and lows treat-ed, and it was a revelation to some thatfinally they were among friends wherediabetes was not unusual or “a bigdeal”.Our nurse, Anne, shared her knowledgeabout good pumping tips, advancedpumping tools and site management.The pumpers showed their friends cre-ative ways to wear their pumps. Gameswere played and I am sure that few gota lot of sleep! I presented a hands-onexperience where the girls selected dif-ferent fruit as ingredients in a mixedfruit salad. We weighed each ingredient,multiplied by the effective carbohydratefactor and then computed the actualcarbohydrate content for each finishedserving. The girls expressed great enjoy-ment of this exercise and gobbled upthe entire salad quickly.At the end of this two-day celebrationof friendship and happiness, many ofthe girls thanked me over and over. Iwas amazed at the great time they had(I had hoped they would enjoy them-selves) and we later heard requests fora repeat performance next year. A few,

I believe, wanted to do this twice ayear. It is my feeling that we accom-plished so much in this fun-lovingapproach, which could not have doneany other way. It is my hope that eachgirl has a great year ahead of them.They have our phone numbers and weeagerly await a call just to say Hi!Best regards,Sue Burgio, MS, RD


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25 years, doctors have learned that, carbo-hydrates affect glucose levels more thansugar does. Henceforth, the flour in theChallah would affect an individual’s glucoselevel just like the sugar would.Nowadays, following a Diabetic diet does-n’t mean staying away from sugar andsweets, but rather keeping trackof carbohydrates consumed. Aperson with Diabetes must beaware of how many carbohy-drates specific foods contain,and how ingesting them affectsblood sugar, in order to achievegood control. An individualmust have the ability to adjustinsulin dosages based on anticipated foodintake and activity level. By testing bloodsugar, eating a known quantity of carbohy-drates, and retesting several times during aspecific time period, people with Diabetescan determine their individual reactions tofood and hopefully avoid complications.Insulin pumps are among the latest technol-ogy available for insulin delivery. “It’s acommon myth that the pump is for a moresevere form of Diabetes, but that’s nottrue,” Rabbi Meisels explains. “It’s just atool to better help control Diabetes, and ithelps people live more flexible lives.Currently, however, Diabetes patients likeRabbi Meisels continue to use traditionalforms of Diabetes control, i.e. finger prick-ing and injections or the pump.Nevertheless, gone are the days whenDiabetes patients had to stick to a strict dietand a meal plan of fixed eating times.“During my Cheder (elementary school)years, we were scheduled to learn straightthrough from 10 a.m. to 2 p.m., but I hadto have a snack in between,” Rabbi Meiselssaid. “We (he, his parents and teachers) hadto make special arrangements for me toleave class for a snack. It was very stressful,it made me feel different, and on top of thatI had to keep my Diabetes a secret.”In the Orthodox community, people have atendency to keep medical conditions such asDiabetes a secret, for fear of not finding asuitable shidduch for the Diabetes patient,or of negatively affecting siblings’ shid-duchim.“People try to hide it if they have anythingdifferent from others,” Rabbi Meiselsexplains. “The main reason is that parentswant their children to be perceived as beingthe same as their friends and peers. Theydon’t want their child to suffer from the

stigma of being a ‘sick child.’ It comes fromtrue love-they want to protect their child.But Diabetes is something that is with you24 hours a day, 7 days a week, 365 days ayear, something you constantly have to con-trol. If someone has to do these things andmake sure no one suspects, it creates atremendous amount of stress. It’s like living

a double life or being a spy in aforeign country. Ultimately,people sacrifice some degree ofDiabetes control because ofthis.While Rabbi Meisels said herespects each individual’s wishfor secrecy and keeps the confi-dentiality of members in his

group, Jewish Friends With Diabetes dis-courages keeping the condition hidden. “Ifyou present something positively, no onewill accept it negatively,” he says. “If you dokeep Diabetes a secret, you send a messageto the world and give people an idea thatDiabetes is something really bad.”He related an anecdote about a 12-year-oldboy, a member of the group, who when hewas first diagnosed kept his Diabetes asecret. The stress of keeping such a largesecret became too much for him, however,and he decided to tell. The boy explainedthe disease via an oral presentation to hisclass. A few months later, Rabbi Meiselsasked the boy if the presentation ruined hisreputation. The boy responded, “No oneeven asks me about it, no one even cares.” As far as the issue of shidduchim goes,Rabbi Meisels said that in his experience,being open about havingDiabetes does not hamperthe shidduch process. “Peoplewho don’t keep theirDiabetes a secret find shid-duchim, normal shidduchim.Hashem finds the right bash-erte for everyone.”Rabbi Meisels foundedJewish Friends WithDiabetes, a Jewish support group for Type 1and Type 2 Diabetics, three years agobecause he wanted to help and educate oth-ers. As he learned new things aboutDiabetes, he said, he would share hisknowledge with others. The organizationgrew from there he noted, adding that he isstill constantly learning new things.The organization provides support and edu-cation for Diabetes patients and their fami-lies through education gatherings, speakers,Shabbatons, one on one consultations,

mostly via phone and email, and throughpublications such as the Going Forward,which comes out twice a year. The variousgroups meet at least twice a year as well, notcounting Shabbatons. Men and womenmeet separately, and there is a separategroup for the families of Diabetes patientsto meet as well.While the meetings and Shabbatons areheld in Monsey, the organization deals withpeople from all over the world. It has awebsite, and two email discussion lists, oneof which, Kosher Low Carb, has 250 mem-bers. The other, FWD has 150 members. Issues addressed at the meetings,Shabbatons and in Going Forward andother publications include, long-termhealth, marriage, having a family, remem-bering shots, blood sugar testing, readingfood labels and learning how different foodsaffect blood sugar. At the Shabbatons, activ-ities include presentations and question andanswer segments by a professional, such asa dietician or a certified Diabetes instructor,games about Diabetes, sharing and bondingprograms, singing and exercise and how todo it properly with Diabetes. Among specifically Jewish issues discussedare fasting, checking blood sugar onShabbos, and Yom Tov foods and customs.Since foods traditionally served on Shabbosand Yom Tov are usually homemade, itdoesn’t come with a label, which can makeit difficult to know the carbohydrate count,Rabbi Meisels explains, saying that in thepublications he teaches people how to cal-culate the carbohydrates in these food items

based on ingredients and serv-ing size. As far as one on one consulta-tion, Rabbi Meisels receives anaverage of 500 emails and 100phone calls a week, accordingto his wife, Mrs. Meisels.“Speaking to the rabbi makesyou realize you are not sick,”Mrs. Meisels said. “You learn

to deal with daily responsibilities, that theyare doable and that everything gets easierwith time.” She noted that she is awed by how her hus-band’s Diabetes has enabled them to helpothers. “It’s beautiful what we becameinvolved in because of his Diabetes. I can-not think of a negative issue about it.”

“IF YOU PRESENTSOMETHING

POSITIVELY, NO ONEWILL ACCEPT IT NEGATIVELY.”

“IT’S BEAUTIFUL WHATWE BECAME INVOLVED IN

BECAUSE OF HISDIABETES. I CANNOT

THINK OF A NEGATIVEISSUE ABOUT IT.

(cont. from page 5)

Friends With Diabetes takes noresponsibility for the kashrus

or quality of its advertisers

Y O M T O V G U I D E

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This section is aptly named yacn miwezn — “sweeter than honey.” Besides forthe obvious reasons: during the month of Tishrei we dip challah in honey, andan apple is dipped in honey on the night of Rosh Hashanah, I had a deeperexplanation in mind.

May grandfather, the Iheler Rav zt”l, was once asked why he often repeatedthe words of other great scholars, as opposed to expressing his own novelTorah thoughts. His answer was to quote a midrash describing an argumentbetween the bee and the spider. The spider gloated to the bee, “You goaround collecting nectar from flowers and fruits in order to make your honey,while I spin webs from my self-made secretions.” The bee wisely replied,“Yes, I take from others. But look at the difference in the products wemake. My collection of nectar helps me produce good and sweethoney!” My grandfather explained, “It is true that Ioften choose not to share my own Torah thoughts,but at least I deliver the beautiful, useful words ofgedolim. This is of greater benefit to the publicthan hearing my own words.”

In the same vein, I would like to point outthat a part of the information you willread in this newsletter was collectedfrom various sources. In order topresent the maximum amount of“sweetness” in this newsletter and tohelp you move “ForWarD”, wesearched through many sources forinformation. These include diabetespublication, actual discussionswith medical professionals, and agathering of many otherpeople’s experiences. Inaddition, many seforim wereresearched and variousRabbanim were contacted.

The word”honey” in the titleemphasizes the beauty of thissection by reminding us thehoney is sweet, although, ormaybe precisely because, it is acollection of many sources.

Sincerely,

Rabbi Hirsch MeiselsJewish Friends with Diabetesoheu,n ohghr


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Rosh HashanahRecipes

The following are recipes for someof the special simanim consumedon Rosh Hashanah as part of a

longstanding Jewish custom (origi-

nating in the times of the Sages).These recipes were first proposed in“The Radiance of Rosh Hashanah”,however, they were modified byNorene Gilletz (one of our cybermembers) to allow for the figuring ofnutrition facts. She cautions that sincethe recipes first appeared as vaguesuggestions, she was forced to makemany assumptions, all of which areonly rough estimates and guidelines;there is no guarantee for exact yieldsor serving sizes.

Note that part of the sugar in theserecipes can be replaced with Splendafor lower carb and calorie counts.

The prayers said when eating thesespecies and a list of the carb counts forthe raw ingredients can be found else-where in this issue.

Credits: The recipes are taken with per-mission from “The Radiance of RoshHashanah” by Rabbi David Meisels.Comments and nutrition facts by NoreneGilletz, food consultant and cookbookauthor of MealLeaniYumm!

Cook sugar until melted andbrowned. Add cooked beansand water and cook 1/2hour.

To substitute Splenda forpart of the sugar: Proceed asabove, using only ¼ cupsugar. When done, stir in ¼cup Splenda and cook a fewminutes longer.

Serving size: ½ cup

Carbohydrates: 43.63 g

If made with Splenda:34.63 g.

Fiber: 6.7 g.

206 calories, 7.97 g protein,0.55 g fat, 0.14 g sat fat, 0mg cholesterol, 287 mgpotassium, 4 mg sodium, 2.6mg iron.

Jewish families the world over traditionally eat certain foods on Rosh Hashanah that serve as hopeful, promising omens for the coming year. The exact foods eaten

differ according to the unique customs followed in various communities.We have compiled a list of some of these symbolic simanim, the basic reason why eachfood is eaten, the short prayer recited before eating, and, finally, the amount of carbs eachfood contains.Remember that you can cut down on the amount of carbs by eating less than the sug-gested serving size! For example, there is no mitzvah to eat a full 4 oz. of the sweetcarrot dish many serve on Rosh Hashanah. You can eat just one tablespoon and con-sume a minimal 1.8 ounces of carbohydrates.Fiber has been subtracted from all carb amounts.

ohbnhxohbnhx

APPLE INHONEY

BLACK-EYEDPEAS (cowpeas) thcur

SNAKESQUASH

tre

SWISS CHARDtekhx

LEEK - h,rf

DATES - ohrn,

POMEGRANATEiunhr

BEETS

CARROTS(Tzimmes)

May You renew for us agood and a sweet year

May our merits increase

May the decree of oursentence be torn asunder;and may our merits beproclaimed before you

May our adversaries beremoved

May our enemies be decimated

May our enemies be consumed

May our merits increase as(the seeds of) a pomegranate

Again, we pray for asweet new year.

May our merits increase.(The Yiddish word for car-rots - irvgn - translates to“increase”.)

vba ubhkg asj,a

veu,nu vcuy

ubh,uhfz ucrha

ubbhs rzd greha

lhbpk utrehu

ubh,uhfz

ubhchut uek,xha

ubhtbua u,rfha

ubhtbua un,ha

ubh,uhfz ucrha

iunhrf

ubh,uhfz ucrha

¼ medium, unpeeled apple= 4.3 gcarb factor: 0.13Honey 1 tsp= 6 g1 tbsp 18 g

1 cup boiled = 25 g (1 tbsp. = 1.6 g)

½ cup uncooked = 3 gcarb factor 0.03

1 leaf - 1 gcarb factor 0.02

¼ cup boiled = 1.7 g

One date = 5.5 g

1 whole fruit (3-3/8” dia.) = 26 gcarb factor: 0.17½ cup boiled = 6.8 g carb factor: 0.08

14 g in 4 oz.for the recipe on page144 in Garden of Eating.(1 tbsp. = 1.8 g)

FOOD PRAYER iumr hvh CARBS

SignificantOmens

Black eyed peas (Rubya)

1 cup beans, cooked and drained

1/2 cup sugar

— or —

¼ cup sugar

¼ cup Splenda

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Cut leek lengthwise,check for worms andwash very well. Blendall ingredients andform into balls. Fry in2 Tbsp. oil.

Servings: 4

C a r b o h y d r a t e s :36.29 g.

Fiber: 1.98 g.

248 calories, 5.29 g protein, 9.25g fat, .76 g sat fat, 41 mg cholesterol,2 mg iron, 141 mg potassium, 253

mg sodium.

Cut leek lengthwise,check for worms andwash very well. Blendall ingredients andform into balls. Fry in2 Tbsp. oil.

Servings: 4

C a r b o h y d r a t e s :36.29 g.

Fiber: 1.98 g.

248 calories, 5.29 g protein, 9.25g fat, .76 g sat fat, 41 mg cholesterol,2 mg iron, 141 mg potassium, 253

mg sodium.

InspectSwiss chard (for insects), and blend.Combine all ingredients. Form intoballs and fry.

Variation: Add more bread crumbsand bake as a kugel.

Servings: About 6

Carbohydrates: 17.54 g.

Fiber: 3.04 g.

135 calories, 5.33 g protein, 5.86 gfat, .54 g sat fat, 27 mg cholesterol,3.5 mg iron, 599 mg potassium,365 mg sodium.

Peelsquash and cut into cubes; cook

until tender and drain water.

Add equal amount of sugarand water.

Cook approx. 1/2 hour untiltender

Servings: About 6

Carbohydrates: 19.42 g.

Fiber: 0.9 g.

77 calories, 0.58 g protein, 0.2 gfat, 0.04 g sat fat, 0 mg choles-terol, 124 mg potassium, 0.8 mgsodium.

Snake Squash (Kara)

1 (1 lb.) Snake squash

(a summer squash, similar

to crookneck squash.)

½ cup sugar

Swiss Chard (Silka)

1 (2 lb.) bunch Swiss Chard

(similar to spinach)

1 egg1 medium onion (sautéed)

1/2 cup flour

¼ cup bread crumbs

Dash of salt

S H A B B O S S U G A R S

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Leek (Karta)1 (1 lb.) bunch leek

1 medium onion

3/4 cup bread crumbs

1 egg1/4 cup sugar

Dash of salt

This list shows the carb amounts of some common fruits onwhich the blessing of shehecheyanu can be recited on RoshHashanah.For a more complete chart of fruits and their effective carb factors,see the Tu B’Shevat section of our winter issue.

SHEHECHEYANU FRUIT: CARB CONTENTS:Star fruit (Carambola); 1 med. fruit = 5 g. Carb factor: 0.05Persimmon; about 16 g.Papaya; about 14 g. in a med. fruit or in 1 cup.Mango; 17.6 g. in a sm. fruit. 14 g. per ½ cupPassion Fruit; 12.6 g. in 3 sm. fruitsCuke Asaurus (Kiwano); 0 grams of carb!Moro (Blood) Oranges; Carb factor: 0.11Kumquats (miniature oranges); Carb factor: 0.16Pepino Melon; Carb factor: 0.07

A Sweet and Successful Year!May all our tefillos be miskabel berachamim uverotzon!

ohbnhxubhhjva ,urhpMonsey Takeout46 Main Street • Monsey, NY 10952

(845)425-2300

TAKE-OUT EAT-IN CATERING

Full line of Great Tasting & “Low Carb”

~ Salads~ Kugels

~ Chicken Disks~ Fish

~ Schwarma

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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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15

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

followi

ng

the

si

gnpost

OurGedolimshowed

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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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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 bolusBedtimeMidnight2-3 amUpon waking

Every 1-2 hours upon wak-ing until lunch

4 hours after breakfastEvery 1-2 hours until dinner

4 hours after lunchEvery 1-2 hours until dinneror 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!

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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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