Fasting on Yom Kippur — Part 1: Where This Started

BS"D

Twenty-five years ago I wrote the first guide to fasting with Type 1, and my Rav told me to call it back. This is how it started — and what he put in writing three years ago.

In this post:

• How It Started
• What This Looked Like in 2001
• What My Rav Told Me Then
• What He Wrote Three Years Ago
• Last Year
• Why I Am Starting Here

For the past twenty-five years I have written something about fasting on Yom Kippur. Every year without fail. Some years it was a full guide. Some years it was a summary of what we had already published. Some years it was nothing more than a list of links to the older newsletters.

They are all still on our site, on the Tishrei page of our guides, going back to the first one.

This year I asked myself the obvious question. Is there anything left to say? My positions on fasting have not changed.

Two things have changed.

The first is that we have a blog. A newsletter gave me one issue a year, and everything had to fit inside it. Here I can take one question at a time and give it a whole post.

The second is that the technology keeps advancing. Every few years the tools change, and the old questions have to be asked again against the new ones. An answer that was right for a person on NPH is not automatically right for a person on a closed loop.

Then a third thing struck me. A quarter century is a long time. The beginning of this is already history.

So that is where the series starts.

How It Started

Back then we were small. I could put a face to every member, and a name to every face, and I knew their phone numbers and their email addresses.

It was also the beginning of a new era. Until then a person with diabetes lived on a schedule somebody else had set. Meals at fixed hours. Snacks whether you wanted them or not. Then came flexible insulin therapy — long-acting insulin covering the body, and a separate dose for food when the food came. The schedule started fitting around the person, instead of the person fitting around the schedule.

I remember working it through in my head. If I can push breakfast off to the afternoon, why can I not skip the meals altogether for one day?

So I wrote out a plan for how I would fast, and my doctor agreed to it.

Then a member called me with the same question. I took him through the plan on the phone. He stopped me. I will never remember all of this, he said. Write it up for me. If I have it on paper I can read it slowly, and I will have something to go back to.

So I wrote it. Three pages, as I remember it. I faxed it to him. Then I faxed it to a second man who asked.

And then I stopped, because I have a Rav.

I walked over to Rav Weismandl shlit"a and put the pages in front of him.

He was furious, and in strong words he told me. This is not responsible. You cannot tell this to anyone. You cannot show this to anyone. I told him I had already faxed it to two people. Call them, he said. Tell them to throw it away.

So I spent the next year doing it the way it should have been done in the first place. I went to doctors. I worked the plan over until it could stand up to them. I got them to put their names to it. To that the Rav already agreed.

The article ran in our Tishrei 5762 issue (September 2001), which went out ahead of Yom Kippur that year — our first Yom Kippur publication, in English and in Yiddish. It carried Rav Weismandl's approval, a teshuvah from him in the same issue, and endorsements printed alongside it from Dr. Don Zwickler and Dr. Henry Anhalt.

Before that article, there was no doctor in the world and no Rav in the world who permitted a person with Type 1 diabetes to fast. Not one. That is what our guidance sheet changed.

About ten years later the same work produced a formal Position Statement on Type 1 diabetes and fasting on Yom Kippur, signed by twenty-six endocrinologists — from Einstein, Yale, Harvard, Columbia, Mount Sinai, Washington, Florida, Pittsburgh, Chicago, Hadassah, Laniado and others. We published it in our own Tishrei 5771 issue, and the following year it ran in the medical journal Pediatric Diabetes. Its acknowledgement thanks me for suggesting that the statement be drafted and for bringing in the authors and many of the signatories. Dr. Zwickler and Dr. Anhalt, the two who had signed on at the very beginning, were both on it.

In the years that followed, doctors around the world handed copies to their patients. I know this because the patients then came looking for me.

What This Looked Like in 2001

Read that first article today and the first thing that jumps out is the equipment.

The background insulins were NPH, Lente and UltraLente, with Regular or Humalog for food. A basal that peaked on its own schedule, whether or not you had eaten.

The pumps in the article are the MiniMed 508 and the Disetronic D-Tron.

And there was no continuous glucose monitor, because there was none to have. The instruction was a fingerstick at least every two hours, through the day and into the night. If you wanted any warning while you slept, there was a device called a Sleep Sentry that you wore on your wrist or ankle, and it tried to catch a low by measuring your perspiration and your skin temperature.

I am not listing this out of nostalgia. Every answer we gave back then was an answer for those tools. Some of those answers still hold. Some do not. Sorting them out is what I want to do in this series.

What My Rav Told Me Then

Rav Weismandl was never against fasting. His caution was about risk — and in those years, with those tools, a person could plan carefully and still be left with something nobody could account for.

In one of our conversations during that period he said something to me that I have never forgotten.

Rabbi Meisels, I do not think you should be fasting. I want you to be the statement that a person with Type 1 diabetes does not have to fast.

That was not a ruling. It was a suggestion, and he left it with me.

I could not bring myself to follow it. Why should I be different from everybody else? But the words stayed with me.

What He Wrote Three Years Ago

Now look at what has happened since. The chronology has moved. The understanding is fuller. The tools are not the tools of 2001.

In Tishrei 5784 (September 2023) — three years ago — Rav Weismandl put his position in writing:

It is entirely clear to me that anyone who has Type 1 diabetes, and who is a person able to manage his blood sugar and accustomed to doing so, is obligated to [try to] fast on Yom Kippur — unless he has an additional medical condition or the like, or his doctor has said of him that he is different from other people who have it.

Menachem Meir Weismandl · 4 Tishrei 5784

The two exceptions in that letter carry the weight. Another condition alongside the diabetes. Or a doctor who says this particular person is different. Everything this series is going to work through lives inside those two criteria.

In the same letter he wrote that I may be relied on to assess whether a person is in a position to fast or not.

Last Year

Weeks before Yom Kippur last year I had an episode of DKA. I wrote about it a little while later, in A Story I Will Never Forget — And the Lesson I Learned.

I was not feeling well for a good while afterward. I was slipping into ketones easily. And Yom Kippur came around while that was still true.

I was squarely inside the exception in his own letter. And his words from all those years earlier came back to me.

For the first time, I did not fast. I did not eat. I did drink.

Why I Am Starting Here

I am telling all of this for one reason.

Where the risk is genuinely accounted for, the obligation stands. But everything depends on whether it really is accounted for, and that is not a question anybody should answer casually about himself.

Fasting with Type 1 diabetes carries real risk. It is not for everyone. It cannot be taken lightly, and it cannot be taken on last year's plan, or on somebody else's.

I am the one who opened this door, and I was stopped at my own Rav's house before I could open it too far. Keep that in mind as this series goes on.

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— Rabbi Hirsch Meisels

P.S. This is Part 1. The rest of the series takes the questions one at a time — including Rav Weismandl's criteria in full, and what the newer technology has and has not changed.