Fasting on Yom Kippur – Part 6: When the Low Has Already Happened

BS"D

It can come at any hour of the day. The number drops under 70, or the symptoms start. And you are the one who has to stop and eat.

Everyone around you is still standing there. You prepared for this day for weeks. You went in wanting to fast, and now, in the middle of it, it is over.

For years I have tried to find the right words to give a person before that moment, because the moment itself is not when anybody goes looking for them.

In this post:

• A Tefillah I Once Printed
• And Then I Took It Back
• A Mitzvah Nobody Else in Shul Has
• What Counts as a Low
• Before It Hits, and After
• Why Measure a Candy at All?
• Take the Candy With a Drink
• If All You Have Is a Drink
• If It Happens Again
• Through the Mouth, and Nothing Else
• The Condition

A Tefillah I Once Printed

In one of our first newsletters I printed a tefillah for exactly this. Sefer Nitei Gavriel brings it from an old machzor, to be said by a person who has to eat or drink on Yom Kippur, the first time he eats or drinks.

The tefillah: הִנְנִי מוּכָן וּמְזוּמָן לְקַיֵּם "מִצְוַת" אֲכִילָה וּשְׁתִיָּה בְּיוֹם הַכִּפּוּרִים כְּמוֹ שֶׁכָּתַבְתָּ בְּתוֹרָתֶךָ, וּשְׁמַרְתֶּם אֶת חֻקּוֹתַי וְאֶת מִשְׁפָּטַי אֲשֶׁר יַעֲשֶׂה אוֹתָם הָאָדָם וָחַי בָּהֶם (ויקרא י"ח ה'). וּבִזְכוּת קִיּוּם הַמִּצְוָה זוּ, תַּחְתּוֹם אוֹתִי וְאֶת כָּל חוֹלֵי עַמְּךָ יִשְׂרָאֵל, לִרְפוּאָה שְׁלֵימָה, וְאֶזְכֶּה בְּיוֹם הַכִּפּוּרִים הַבָּא לְקַיֵּם שׁוּב וְעִנִּיתֶם אֶת נַפְשׁוֹתֵיכֶם, כֵּן יְהִי רָצוֹן אָמֵן (Nitei Gavriel).

I am ready and prepared to fulfill the mitzvah of eating and drinking on Yom Kippur, as You wrote in Your Torah: "And you shall guard My statutes and My laws, which a person shall fulfill and live by them" (Vayikra 18:5). And in the merit of fulfilling this mitzvah, seal me and all the sick of Your people Yisrael for a complete recovery, and may I merit next Yom Kippur to fulfill once again "and you shall afflict your souls." So may it be Your will, amein.

And Then I Took It Back

The Rishonim ask why we make no bracha before giving tzedakah. The answer is that in the meantime the poor man could die of hunger.

The same applies here. A person with a low blood sugar cannot give away an extra second.

So it does not belong at that moment. It can be said afterward. And it can be said before, in the case where the number is heading down and the low has not arrived yet, when there are still a few seconds to spare.

So at the moment itself there is no tefillah to say. Which means a person needs something else to hold onto when the fast suddenly has to stop – and I looked for it this year, and found it in a Gemara.

A Mitzvah Nobody Else in Shul Has

The Mishnah says (73:2) Yom Kippur is forbidden in eating and drinking. The Gemara asks: forbidden? It carries the כרת penalty. Rabbi Ila answers that the Mishnah is teaching about a chatzi shiur, less than the measure.

The Tosefes Yom HaKippurim asks why the Tanna teaches chatzi shiur here more than by other prohibitions. His answer is the piece worth carrying. One might have thought that only a full measure is forbidden, because a full measure settles a person – yishuv hadaas. Less than a measure settles nothing. On the contrary, it is more painful for him, because he has started his appetite without satisfying it.

He says it only as a hava amina, a thought one might have had. But the sevara itself stands: eating in small amounts is a greater inui than eating nothing at all. It wakes the hunger and never answers it. For everybody else the thought gets pushed aside, because a chatzi shiur is forbidden and there is no way to act on it.

For us it is not a hava amina at all. The eating itself is the mitzvah. So the sevara comes back and stands: a person who eats on Yom Kippur because the body needs it is fulfilling "ועניתם את נפשותיכם" ve'inisem es nafshoseichem b'hidur – with more inui than the person standing next to them who is not eating at all.

That is a mitzvah nobody else in the room has.

What Counts as a Low

Either one of these is a low:

• A number below 70 – which means 69.
• Symptoms, with no number at all.

Either one on its own. You do not need both.

Our Rav paskened that the signs of a hypo are considered simanei hisalfus, the signs of fainting, and that a person who has them carries the din of a choleh sheyesh bo sakanah. There is nothing there to weigh.

And that is so even when you still feel fine in yourself. By the time those signs are there, the brain is already not working the way it should.

And the number can be wrong. A fasting body is dehydrated, and readings are less reliable when you are dehydrated – the sensor can show 70 when you are 50. A screen that looks fine is not an answer to a symptom you are feeling.

Before It Hits, and After

These are two different situations with two different rules, and mixing them up is where people get stuck.

The blood sugar is heading down and the low has not arrived yet. Here you can still eat pachos m'kshiur, less than the measure. If it stops dropping and the symptoms subside, you have treated it and you are still considered fasting.

When the low is already here, there are no shiurim. You treat immediately.

Why Measure a Candy at All?

Our Rav went and measured this for us himself. He crushed Winkies into a measuring cup and found that four full rolls are still less than the shiur. Four full rolls – not four small candies. A roll is fifteen tablets, about 6 grams of carb. (Winkies are sold as Fizzers, and as Smarties in the American stores.)

Which raises a question. If once the low is here you take what you need and stop counting, what is that measurement for?

It is not for that case. It is for the one before it – the arrow of the blood sugar reading is slanted downwards, the low has not landed yet, and you want to head it off without breaking the fast. There, amounts are everything. Stay under the shiur and you have not eaten on Yom Kippur in the way the day forbids. So a person has to know what "under the shiur" looks like in a candy you are actually holding in your hand.

Once the low is there, that whole calculation is gone. No measuring, no counting, no rationing. You take what brings the number up.

So the two rulings are not standing against each other. They belong to two different moments, and the measurement belongs to the first one.

And here is something worth knowing, even though you should not be thinking about it at the moment of a low. Nobody treating a low needs four rolls. One roll is 6 grams. Two rolls is 12. Add 40 milliliters of juice and that is another 4 or 5. Around 16 grams altogether, which is an ordinary treatment for a low. So in practice you land under the shiur anyway, without trying to.

This is a mindset, not a rule. At the moment of a low there are no measures. You are not rationing yourself because it is a fast day. You do what you have to do – and if it happens to come out less than the shiur, good.

Take the Candy With a Drink

On a fast day your mouth is dry and everything in the digestive system is moving slower. A candy sitting in a dry mouth is not doing very much for you, and not quickly enough.

So take the candies together with something to drink. The liquid washes them down and gets them where they need to go. The drink is not instead of the candy; it is carrying it.

And remember that you can eat and drink at the same time. Eating and drinking are two separate measures. Two rolls of Winkies and 40 milliliters of juice are two separate amounts, each one under its own shiur – not one larger amount. That is why the combination is the practical answer in the case where you are heading a low off before it lands.

If All You Have Is a Drink

Forty milliliters of juice is not going to bring up a low. So the mind starts looking for a way around it – and the way it finds is the wrong one. Half a minute between sips, the most lenient waiting time, and in that way you can get a good amount in without ever taking a full shiur at once. That is exactly where the Rav's psak comes in. Once the low is there, you drink what you need, in one sitting, with no waiting at all.

If It Happens Again

It can happen more than once. Treat the second one the way you treated the first, and the third the same way. There is no counting here either. Every low gets treated when it comes.

What repeated lows are telling you is something about your settings, not about you. On a day with no food, a basal that is a little too strong keeps pulling you down, and it will go on doing it until the fast is over. That is worth sitting down with afterward and looking at properly. During the fast it changes nothing at all about what you do. The low comes, you treat it.

And do not turn to the pump to stop it. The instinct after the second low is to cut the basal, or suspend it, so that it does not happen again. Do not. The insulin has to keep flowing – it is what keeps you out of DKA. A low you treat with a drink. DKA is not treated with a drink. So let the insulin run and treat the lows as they come.

Through the Mouth, and Nothing Else

Our Rav has ruled that a person with a low blood sugar on Yom Kippur does not use any workaround to bring it up other than breaking the fast. No intravenous glucose. No glucagon. No suppositories. Through the mouth, and nothing else.

And after a day of fasting, glucagon may not do very much anyway. It works by pulling sugar out of the liver, and by that point the liver's stores are already depleted.

This is halacha.

The Condition

Our Rav set a condition on a person who takes insulin fasting at all. You have to be fully committed, before the fast begins, that if a low happens you are going to eat or drink. No hesitation.

And this is why it has to be decided in advance. A brain short on glucose does not think straight. The thinking that says let me wait a few more minutes and see is itself a symptom of the low. You cannot check your own judgment with the same brain that is running low – so the judgment has to be made now, before Yom Kippur, and carried into the day already made.

I know that when the moment comes it is a very hard decision. And it is easy to say: let me wait. Let me see what happens. After all, I have a sophisticated pump, a good AID system. Let me see what it can do.

No. You cannot. If you see that number, or you have that symptom, there is no waiting. Because if you do not treat it right away, you were not allowed to fast to begin with.

Ask yourself why you want to wait. Because you want the mitzvah of fasting. But the waiting is the proof that you were never supposed to fast at all.

Your mitzvah now is the cup in your hand. Take what the low needs, and every hour you fasted until this moment was a mitzvah. That was one mitzvah. Breaking it now is a second one.

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Wishing you a kesivah vechasimah tovah, and an easy fast.

– Rabbi Hirsch Meisels

P.S. This is the second post today. I usually keep to one. Yom Kippur is close, and anything I have to say about it has to go out now rather than wait its turn in line.