Original Article
MANAGEMENT OF DIABETES MELLITUS
ON YOM KIPPUR AND OTHER JEWISH FAST DAYS
Martin M. Grajower, MD, FACP, FACE
ABSTRACT
Objective: To create guidelines for patients with dia-
betes to fast safely on Yom Kippur and other Jewish fast
days, with the primary goal of avoiding hypoglycemia.
Methods: Almost 30 years of experience in endo-
crinology and the pharmacokinetics and pharmacodynam-
ics of current drug therapy were applied to develop these
guidelines and recommendations. A few illustrative cases
are presented.
Results: Patients with either type 1 or type 2 diabetes
were able to fast safely when a treatment plan was proac-
tively formulated before the fast day. An understanding of
which medications lower basal and which lower prandial
blood glucose levels, as well as their duration of action, is
critical.
Conclusion: The overwhelming majority of patients
with type 1 or type 2 diabetes can, from the perspective of
blood glucose control, safely fast on Yom Kippur.
Physician-patient discussion is important to prevent the
patient from relying only on personal judgment and poten-
tially taking too much medication, with the resultant
development of hypoglycemia. (Endocr Pract. 2008;14:
305-311)
Abbreviation:
A1C = hemoglobin A1c
INTRODUCTION
Tailoring treatment for diabetes to an individual
patient’s lifestyle, rather than altering patient behavior to
conform to a preconceived treatment plan, can result in a
Submitted for publication August 6, 2007
Accepted for publication September 10, 2007
From the Division of Endocrinology, Albert Einstein College of Medicine,
Bronx, New York.
Address correspondence and reprint requests to Dr. Martin M. Grajower,
3736 Henry Hudson Parkway East, Bronx, NY 10463.
© 2008 AACE.
more compliant patient and an improved physician-patient
relationship. One issue confronting Jewish patients with
diabetes is fasting on the holy day of Yom Kippur (Jewish
Day of Atonement). Many Jews observe 5 additional 1-
day fasts throughout the year: the Ninth of Av, which lasts
25 hours (beginning from sunset and lasting until about 1
hour after sunset the following day) like Yom Kippur, and
4 others lasting only from morning until night (from sun-
rise to after sunset). These special days of fasting pro-
scribe the intake of all food and liquids (including water)
and, especially in the case of Yom Kippur, the holiest day
of the Jewish year, occupy an extremely important place in
Jewish religious observance.
When patients with diabetes ask their clinicians
whether they may fast, the clinicians must have knowl-
edge of the scientific facts as well as sensitivity to the feel-
ings of each patient, including both religious and health
concerns. When physicians have carefully considered the
individual needs of each patient, rather than issuing a blan-
ket statement that “patients with diabetes should not fast,”
Jewish law would generally mandate that patients listen to
their physicians, especially those who are specialists.
As an Orthodox Jew and practicing endocrinologist, I
try to synthesize Jewish law with good medical practice.
Each year, rabbis call me regarding people with type 1 or
type 2 diabetes who were told by their physicians (includ-
ing endocrinologists) not to fast. My nearly 30-year expe-
rience has been that, from the perspective of blood glucose
alone, almost all patients not taking insulin can safely fast.
The main exception is a patient with acute lack of
glycemic control in danger of dehydration. (Such a patient
probably needs insulin and is therefore not actually an
exception.) The vast majority of patients taking insulin can
also safely fast, again with consideration of just blood
glucose control.
ILLUSTRATIVE CASES
Case 1
A 55-year-old man had had type 2 diabetes for more
than 20 years. His most recent hemoglobin A1c (A1C)
was 6.5% during treatment with a regimen of glipizide-ER
(extended release), 10 mg twice a day; exenatide, 5 µg
twice a day; and metformin, 1,000 mg twice a day.
ENDOCRINE PRACTICE Vol 14 No. 3 April 2008 305
306 Diabetes and Yom Kippur, Endocr Pract. 2008;14(No. 3)
Because he experienced hypoglycemia about every 6
weeks (mainly after exercise), his endocrinologist advised
against fasting because of a concern about a potential
hypoglycemic episode. Independently, the patient attempt-
ed fasting on the Ninth of Av. After taking his usual
evening medicine, he ate dinner before the onset of the fast
at sunset but skipped his usual 15-g carbohydrate bedtime
snack. At 6 AM the next morning, he experienced hypo-
glycemia with a blood glucose level of 57 mg/dL.
Therefore, he was referred to me for advice regarding fast-
ing on Yom Kippur. I advised him to take exenatide and
metformin, but skip glipizide-ER, in the evening before
beginning the fast. He took no medication on Yom Kippur
day, nor did he check his blood glucose all day because he
felt well. At the termination of the fast, prior to eating, his
blood glucose level was 95 mg/dL.
Case 2
A 72-year-old man had a 42-year history of type 1
diabetes. Although an observant Orthodox Jew, for 40
years he had not fasted on Yom Kippur, explaining that he
assumed he could not fast if taking insulin (although he
did not recall asking his physicians). Two years ago, when
he became my patient, I inquired about adjusting his
insulin so he could fast on Yom Kippur. He was elated at
the suggestion. His most recent A1C was 5.6% during use
of a regimen of 10 U of insulin detemir (Levemir) at bed-
time plus preprandial insulin lispro (Humalog) based on
carbohydrate counting. I recommended that he take his
usual insulin lispro dose before the pre-fast dinner but only
5 U of insulin detemir at bedtime. He was to check his
blood glucose in the morning and then every 6 hours: if it
declined below 60 mg/dL or he was symptomatic, he was
to take a sugar tablet; if it was 150 mg/dL or more, he was
to take 2 U of insulin lispro. On the morning of Yom
Kippur, his blood glucose level was 286 mg/dL. He chose
not to take insulin then or 4 hours later, when it was 249
mg/dL. At the end of the fast, his blood glucose was 193
mg/dL. He took his usual insulin lispro dose before his
“break-fast” meal. Two hours later, his glucose value was
64 mg/dL.
Case 3
An 84-year-old Holocaust survivor with a 15-year
history of type 2 diabetes, requiring insulin the past 5
years, had always fasted on Yom Kippur. She was taking
NovoLog Mix, 46 U before breakfast and 26 U before sup-
per. Her last A1C was 6.4%, with home blood glucose
determinations ranging from 110 to 150 mg/dL fasting and
90 to 210 mg/dL postprandially. I advised her to take her
usual NovoLog Mix dose before dinner prior to the fast
but only 10 U of NovoLog Mix on the morning of Yom
Kippur. She was to check her blood glucose the first thing
in the morning, then 2 hours after administration of her
insulin, and again 6 hours later. She was to take a sugar
tablet if her glucose value declined to less than 65 mg/dL.
Her blood glucose levels on Yom Kippur were as follows:
fasting, 151 mg/dL; 2 hours later, 96 mg/dL; 2 hours later,
79 mg/dL; and before the meal that concluded her fast,
130 mg/dL.
CONCEPTS
During the past decade, the treatment of diabetes has
become quite complex with the introduction of many new
medications. Accordingly, I believe that understanding
certain concepts would be helpful before outlining my
approach to the individual patient.
Most importantly, because each patient will be fasting
as infrequently as once a year (Yom Kippur) and up to a
maximum of 6 times, the main objective is to avoid hypo-
glycemia, which would require the patient to terminate the
fast.
An understanding of which medications lower basal
and which lower prandial blood glucose levels, as well as
their duration of action, is critical. Medications with 24-
hour duration will have an effect on the blood glucose
level well into the fast day, whereas shorter acting medi-
cines will exert their effect only on the pre-fast dinner.
Similarly, when insulin doses are adjusted, the main
consideration is the duration of action of the prescribed
insulin. Therefore, before daytime-only fasts (sunrise to
sunset), because the patient eats normally the night before
the fast, no need exists for adjustment of any short-acting
prandial evening medications. One exception is if the
patient tends toward hypoglycemia during the night or
early morning; in such a case, I would reduce the dose
of the medication (tablets or insulin) that is likely causing
this hypoglycemia. In contrast, because prior to a 25-hour
fast the patient may eat dinner earlier than usual and will
not have a bedtime snack, the before-dinner medication
may need adjustment to avoid nighttime hypoglycemia.
On the morning of the fast, patients with type 2 dia-
betes rarely need medication. Even if the blood glucose
level is high, the lack of ingestion of carbohydrates will
improve insulin sensitivity and lower the level of blood
glucose. In contrast, patients with type 1 diabetes do need
some basal but not short-acting insulin unless the blood
glucose values are high (arbitrarily, I use 250 mg/dL,
keeping in mind the first concept).
A final consideration is the potential for each medica-
tion to cause hypoglycemia, either alone or in combination
therapy. Glucose-dependent medicines (biguanides, thia-
zolidinediones, and exenatide) rarely cause hypoglycemia.
The other main therapeutic objective is to avoid
hypotension, especially in older patients (see subsequent
discussion of concurrent conditions). Everyone who
refrains from eating or drinking for 25 hours will become
dehydrated, and many otherwise healthy people will expe-
rience a decrease in their blood pressure as a result.
 Diabetes and Yom Kippur, Endocr Pract. 2008;14(No. 3) 307
GUIDELINES
As mentioned, the main objective is avoiding hypo-
glycemia. Should hypoglycemia occur and the patient
must discontinue the fast, then the therapeutic plan did not
accomplish its purpose. On the other hand, should the
blood glucose level increase during the course of one day,
it will not create either a short-term or a long-term prob-
lem (see pregnancy exception discussed subsequently). If
anything, fasting itself has been shown to lower the blood
glucose level quite effectively (1). I continue all medicines
as usual the morning before the day of fasting. I do not
give any glucose-lowering medication (except insulin; see
subsequent information) on the day of the fast itself. After
the fast is over, I resume all medications at their usual
times (that is, I do not have the patient take a tablet at night
that normally would have been taken that morning).
Therefore, the following guidelines refer to medication
taken either at noon or later during the day preceding the
fast and to insulin on the day of the fast itself (Table 1).
Antihyperglycemic agents that do not cause hypo-
glycemia (biguanides and thiazolidinediones) can be taken
as usual before the fast. Although dipeptidyl-peptidase-4
inhibitors rarely cause hypoglycemia when used alone,
they have been shown in clinical studies to result in hypo-
glycemia in combination with other agents (including met-
form and thiazolidinediones) (2,3). Because of their long
half-life, they should not be taken later than the morning
preceding the onset of the fast. Other medicines with a
long half-life, such as sulfonylureas, should also not be
taken later than the morning before the fast because their
prolonged action extending into the day of the fast could
cause hypoglycemia. Those medications with shorter half-
lives, such as the short-acting insulin secretagogues
(repaglinide and nateglinide), incretin mimetics (for exam-
ple, exenatide), and amylin (Symlin), can be taken before
supper on the day before the fast, inasmuch as this will be
the patient’s normal (or even increased) meal.
Insulin regimens always need to be adjusted begin-
ning with the evening before the fast. In general, the
degree of glycemic control during the 1 to 2 weeks pre-
ceding the fast day will influence the reduction in the
insulin dose. Bolus or short-acting insulin should be taken
as usual before supper on the night before the fast. I
always aim to use some basal insulin (intermediate- or
long-acting) during the fast (regardless if the basal insulin
is taken at night or in the morning). I reduce the dose to
one-third to one-half of the usual dose (based on the A1C)
for a 25-hour fast. For a daytime-only fast, I reduce the
dose to about 80% of the usual basal insulin dose. The bet-
ter controlled the blood glucose levels are preceding the
fast, the less basal insulin I recommend. I also reduce the
dose of evening basal insulin if the patient normally has a
bedtime snack, inasmuch as the snack will not be taken the
night of Yom Kippur or the Ninth of Av. Bolus or short-
acting insulin is taken before eating the meal that con-
cludes the fast; because many people will actually eat less
than their usual amount at this meal, a slightly reduced
dose may be indicated.
When in doubt about how much insulin to recom-
mend, I err on the side of a lower dose. A high blood glu-
cose level can be subsequently corrected without
“breaking” the fast by having the patient take additional
small doses of short-acting insulin.
The combination insulins pose a slightly more diffi-
cult adjustment. I generally reduce the dose to one-half to
one-third of the usual dose, depending on the A1C.
Ideally, the patients could take just the intermediate com-
ponent of the combination insulin on the morning of the
fast day. This approach, however, would entail buying
additional insulin. Therefore, I tend to undertreat rather
than overtreat these patients.
Patients with an insulin pump should not administer a
bolus of any insulin once the fast has begun (unless the
blood glucose level exceeds 250 mg/dL). They should
decrease the basal rate by about 10% beginning in the
early morning (earlier if they normally take a bedtime
snack) and increase the frequency of blood glucose test-
ing, especially the first time they fast using the pump.
DEALING WITH HYPOGLYCEMIA ON THE
FAST DAY
The rules regarding eating and drinking on Yom
Kippur (and, according to some rabbinic authorities, also
on the Ninth of Av) (4) differ from the other Jewish fast
days. Accordingly, on Yom Kippur if patients have symp-
toms of hypoglycemia, or document a blood glucose level
of less than 60 mg/dL, I advise them to take one of the
commercially available glucose tablets (rather than real
food or drink) and to retest the blood glucose in 30 to 60
minutes. If patients have sustained hypoglycemia for a 1-
to 2-hour period, the fast should be discontinued and food
eaten. My threshold for recommending that the fast be ter-
minated is inversely proportional to the age and general
health of the patient. On the other Jewish fast days,
because Jewish law views any oral intake as terminating
the fast (4), I advise patients simply to break the fast if
symptoms occur or the blood glucose level decreases
below 60 mg/dL.
CHECKING BLOOD GLUCOSE ON YOM KIPPUR
Yom Kippur differs from the other Jewish fast days
also in that there is a prohibition against drawing blood
and using electrical devices (such as blood glucose
meters), unless necessary to preserve the sanctity of life.
On the other Jewish fast days (including the Ninth of Av
according to all rabbinic authorities), these prohibitions do
308 Diabetes and Yom Kippur, Endocr Pract. 2008;14(No. 3)
Table 1
Guidelines for Adjusting Antihyperglycemic Medications on 25-Hour Fast Days
(Yom Kippur and the Ninth of Av) That Last From Sundown Until After Sunset the Next Day
and Fasts That Last Only From Sunrise to Sunset on the Same Daya
Fast days Type 2 diabetes
and related Not taking Taking insulin
timing insulinb and oral agents
25-Hour fast days (Yom Kippur and Ninth of Av)
Night before Do not take SU or Do not take SU or DPP-4
DPP-4 inhibitors; inhibitors; take all other
take all other medications before the
medications normally last meal. Take usual
taken before supper dose of short-acting
insulin before supper and
one-half to one-third the
usual evening dose of
intermediate-acting or
basal insulin
Day of fast Do not take any Do not take any
medications medications
including insulin
After the fast Resume all usual Resume all usual presupper
presupper and and bedtime medications;
bedtime medications adjust dose of short-acting
insulin if patient will be
eating a smaller supper
than usual
Daytime-only fast days
Night before Do not take SU or Do not take SU or DPP-4
DPP-4 inhibitors; inhibitors; take all other
take all other medications before the
medications before last meal. Take usual
the last meal dose of short-acting
insulin before supper;
reduce dose of
intermediate-acting or
basal insulin by 20%
Day of fast Do not take any Do not take any medications
medications including insulin. Take
short-acting insulin
analogue if blood glucose
>250 mg/dL
After the fast Resume all usual Resume all usual presupper
presupper and and bedtime doses; adjust
bedtime medications dose of short-acting insulin
if patient will be eating a
smaller supper than usual
aDPP-4 = dipeptidyl-peptidase-4; SU = sulfonylureas.
bIncludes all orally administered agents and injectable incretin mimetics.
Taking only
insulin
Take usual dose of short-
acting insulin before supper
and one-half to one-third the
usual evening dose of
intermediate-acting or
basal insulin
Do not take any insulin
unless blood glucose >250
mg/dL (then take some short-
acting insulin analogue, and
aim to lower only to 110-140
mg/dL range)
Resume all usual presupper
and bedtime doses; adjust
dose of short-acting insulin
if patient will be eating a
smaller supper than usual
Take usual dose of short-
acting insulin. Reduce
intermediate- or long-acting
insulin to about 80% of the
usual dose
Do not take any insulin
unless blood glucose >250
mg/dL (then take some short-
acting insulin analogue, and
aim to lower only to 110-140
mg/dL range)
Resume all usual presupper
and bedtime doses; adjust
dose of short-acting insulin
if patient will be eating a
smaller supper than usual
Type 1 diabetes
Take usual dose of short-acting
insulin before supper and one-
half to one-third the usual
evening dose of intermediate-
acting or basal insulin
Take one-half to one-third the
dose of basal or intermediate-
acting insulin in the morning.
Take short-acting insulin
analogue only if blood glucose
>250 mg/dL, and aim to lower
only to 110-140 mg/dL range
Resume all usual presupper and
bedtime doses; adjust dose of
short-acting insulin if patient
will be eating a smaller supper
than usual
Take usual dose of short-acting
insulin. Reduce intermediate-
or long-acting insulin to about
80% of the usual dose
Take one-half to one-third the
dose of intermediate-acting or
basal insulin, but no short-acting
insulin unless blood glucose
>250 mg/dL (except in patients
on combination insulins; see text)
Resume all usual presupper and
bedtime doses; adjust dose of
short-acting insulin if patient
will be eating a smaller supper
than usual
 Diabetes and Yom Kippur, Endocr Pract. 2008;14(No. 3) 309
not apply, and the patient can, and therefore should, check
the blood glucose freely. Therefore, the following guide-
lines apply only to Yom Kippur.
Patients taking no antihyperglycemic medications are
not at risk for developing hypoglycemia and therefore
need not check their blood glucose level during the entire
25-hour fasting period. Patients taking antihyperglycemic
agents (excluding insulin) who are known to have good
hypoglycemia awareness also need not check their blood
glucose level, unless they begin to have symptoms (some
of the symptoms usually associated with hypoglycemia,
such as tachycardia, could represent dehydration and
hypotension, and the blood glucose should therefore be
checked). Elderly patients or those with documented
hypoglycemia unawareness should check their blood glu-
cose level upon arising on the morning of the fast and then
every 4 to 6 hours (sooner if glucose values decline below
70 mg/dL), unless their only medications are those that do
not cause hypoglycemia (as discussed previously).
I recommend that all patients taking insulin test their
blood glucose level upon arising on the morning of the fast
and then every 4 to 6 hours (sooner if glucose values are
below 70 mg/dL or the patient is symptomatic). I advise
supplemental rapid-acting insulin analogues (lispro,
aspart, or glulisine; NOT regular insulin) for blood glu-
cose levels greater than 250 mg/dL; I try to aim for a blood
glucose value in the range of 110 to 140 mg/dL.
WRITTEN RECOMMENDATIONS
On the basis of my experience, I recommend that the
physician provide the patient with written recommenda-
tions that are made. In these written recommendations, I
include the following information: (1) changes in medica-
tion before, during, and after the fast, (2) frequency of
blood glucose testing, and (3) “what if” planning for ter-
minating the fast if the blood glucose level declines below
a specific value or the patient becomes symptomatic.
Besides improving compliance by the patient, the written
recommendations become a part of the patient’s medical
records. I will generally follow-up with the patient at the
next office visit to learn how the patient fared on the fast
day and note these comments for use the subsequent year.
In most patients, I refer back to these written recommen-
dations, which make it easier to advise the patient the fol-
lowing year.
MANAGEMENT OF CONCURRENT CONDITIONS
A detailed discussion of how to manage concurrent
conditions on a Jewish fast day in patients with diabetes is
beyond the intent of this article. A few short guidelines,
based on my own experience and discussions with experts
in the specific specialties, seem appropriate.
In general, swallowing pills is not considered “break-
ing” a fast (4). Liquids and chewable tablets, however, are
a problem. The main issue with most pills is, therefore, not
the taking of the medicine itself but the drinking of water
in order to swallow them. Although there may not always
be consensus among Orthodox rabbis, a frequently quoted
opinion allows drinking of aliquots of just under 30 mL of
water at intervals of 9 minutes (4). Except where noted,
the following recommendations all refer to taking medi-
cines on the day of the fast itself, not before the fast begins.
When in doubt about a specific medication, a useful
approach is to ask yourself the following question: If the
patient went away for the weekend and forgot to take his
medications, and would not return home for 24 hours,
would you recommend finding the nearest pharmacy and
getting an emergency supply (such as for corticosteroids
for a patient with adrenal insufficiency or warfarin in a
patient receiving anticoagulation therapy), or would you
reassure the patient that a day’s dose could be missed
(such as for statins or levothyroxine) or the dose could be
doubled on return home (such as for propylthiouracil or
diphenylhydantoin)? Once-a-day medications that need
not be taken fasting (for example, warfarin) can often be
taken just before and then again just after the fast.
Hypertension
Blood pressure medications are often the most chal-
lenging to adjust. On the one hand, skipping the medica-
tion could result in excessive elevation of the blood
pressure. On the other hand, because the patient will not be
drinking or eating, there is the risk of dehydration and
resultant hypotension, compounded if the patient is taking
antihypertensive medication. I advise continuation of all
the usual medications before the fast. On the fast day
itself, I recommend skipping all antihypertensive medica-
tions including diuretics, with the exception of β-adrener-
gic blocking agents and clonidine, which I continue. If the
blood pressure has been controlled to 120/70 mm Hg or
less, I reduce the dose of the β-adrenergic blocking agent
or clonidine. After the fast is over, I have patients take
whatever they would normally take at night. I do not
“make up” for any missed doses from the morning or mid-
day.
Cardiac Conditions
The overwhelming majority of patients with stable
cardiac conditions tolerate fasting well. Recommendations
regarding cardiac medications need to be individualized to
the patient, on the basis of the extent of disease and the
chronicity and stability of the conditions and associated
symptoms. Morning medications for angina, arrhythmias,
and congestive heart failure should, as a rule, be taken as
usual. Evening oral medications may be taken during the
evening before the beginning of the fast as well as after the
conclusion of the fast on the following evening. Patients
who are deemed by their physician to have a condition sta-
ble enough to fast should not take their diuretics on the
morning of the fast. Medications that are taken for cardiac
indications but also lower blood pressure (such as nitrates,
angiotensin-converting enzyme inhibitors and angiotensin
310 Diabetes and Yom Kippur, Endocr Pract. 2008;14(No. 3)
receptor blockers, and calcium channel blockers) should
be evaluated on the basis of the patient’s symptom histo-
ry, concurrent medications, and blood pressure readings,
to avoid the development of hypotension while the patient
is fasting.
Conditions Involving Corticosteroid Therapy
In order to avoid either the development of hypoten-
sion from adrenal insufficiency (compounded with the
potential hypotension from dehydration) or a flare-up of
the underlying illness for which the corticosteroids were
prescribed, I do not change corticosteroid dosages.
Pregnancy
Many pregnant women have been advised by their
obstetricians not to fast on Yom Kippur for no reason
other than the fact that they are pregnant. There is no med-
ical literature to support such a recommendation, yet an
abundance of Judaic law supports fasting (5) (but only on
Yom Kippur and the Ninth of Av, not on the other 4
Jewish fast days, when pregnant women need not fast) (5).
I am aware of one medical study that assessed the safety
of a pregnant woman fasting on Yom Kippur and con-
cluded that fasting can hasten the onset of labor and deliv-
ery, but only in full-term fetuses (6). The authors found no
increase in premature births or fetal distress in pregnant
women who fasted on Yom Kippur. Similarly, a study of
more than 13,000 babies born to Muslim women who fast-
ed during Ramadan found no effect on birth weight (7).
In pregnant women with diabetes, whether gestation-
al or otherwise, the diabetes is controlled by either dietary
means or insulin. For those with diet-controlled diabetes,
there appears to be no difference during fasting than for
nondiabetic pregnant women; fasting should, if anything,
improve their diabetes control without an increased risk of
hypoglycemia. A pregnant woman receiving insulin is an
exception to the general considerations already outlined;
in such patients, physicians should attempt to avoid any
days of hyperglycemia because of the potential harmful
effects on the fetus. Accordingly, I do not advise fasting
for a pregnant woman with either gestational or preexist-
ing diabetes who is receiving insulin therapy.
DISCUSSION
Jewish law requires all female subjects 12 years and
older and all male subjects 13 years and older to fast dur-
ing the year, especially on Yom Kippur. At the same time,
Jewish law teaches that the sanctity of life overrides all
these fasts (4). If a person would in any way be risking his
health by fasting, not only should he not fast, in fact he
must eat or drink (4).
When the physician, after considering the scientific as
well as religious issues, continues to believe that a specif-
ic patient might be endangering himself by fasting, yet
finds that the patient feels strongly about proceeding with
the fast, the patient should be encouraged to discuss the
situation with a rabbi. In the case of Yom Kippur, and pos-
sibly the Ninth of Av, a compromise position may be rec-
ommended by the rabbi, whereby the patient drinks or eats
in small quantities and at specified intervals throughout
the day rather than having 3 normal meals (4). On the
other 4 fast days, once a person has to eat, there is no reli-
gious reason to limit food intake.
My literature review revealed no published guidelines
for managing diabetes on Jewish fast days. In 2005, rec-
ommendations for management of fasting during
Ramadan were published, based on a meeting of endocri-
nologists and diabetologists from various countries (8).
These recommendations are not applicable to fasting on
Yom Kippur for several reasons. First, the daily fast dur-
ing Ramadan begins after breakfast, which is eaten before
sunrise, and lasts until sunset that evening, not 25 hours.
Second, the fast days during Ramadan last an entire
(lunar) month, whereas Jewish fast days occur one at a
time, separated by anywhere from 1 week to several
months, and are limited to, at most, 6 during the entire
year. Third, Muslims maintain their usual activity level
while fasting during Ramadan, whereas on Yom Kippur,
Jews rarely go to work and generally spend the majority of
the day sedentary in synagogue.
Several studies have been conducted in which patients
with type 2 diabetes receiving no hypoglycemic medica-
tions fasted for 3 to 10 days consecutively, during which
drinking of noncaloric liquids was allowed (9). These
studies are relevant to the Jewish fast days in that they
demonstrated the safety of zero caloric intake in terms of
both not developing hyperglycemia or other metabolic
derangements as well as not developing hypoglycemia.
The relevance of these studies is limited in that they did
allow liquid intake. In addition, because the patients in
these studies had discontinued all hypoglycemic therapy
for at least 6 months, they did not demonstrate the safety
of taking hypoglycemic agents just before fasting.
In a study done on 15 patients with type 1 diabetes
treated with bedtime insulin glargine and prandial rapid-
acting insulin, the authors showed that if these patients
fasted for 18 hours after their usual dose of glargine, but
did not take any rapid-acting insulin, the average blood
glucose level declined by 32 mg/dL, and mild hypo-
glycemic symptoms developed in only 2 patients (10).
This study demonstrated the safety of fasting with use of
long-acting insulin. By reducing the dose of the long-act-
ing insulin, which the authors of that study did not do, one
can substantially decrease the risk of hypoglycemia.
In my 30-year experience in practice, the most com-
mon reason a patient with diabetes could not complete a
fast was not attributable to hypoglycemia or hyper-
glycemia but because of dehydration and resultant
hypotension. Therefore, one of my criteria for advising a
patient with diabetes not to fast is my concern regarding
dehydration. Examples of such scenarios would be a
patient who has had considerably out-of-control blood
glucose levels during the 2 weeks before the upcoming
 Diabetes and Yom Kippur, Endocr Pract. 2008;14(No. 3) 311
fast day, a patient who has recently had a cerebral hypox-
ic event, or a patient with an underlying cardiac condition
who tends to have low-normal blood pressure readings.
Moreover, external factors must be considered. For exam-
ple, a heat wave around the time of the fast day would
increase the possibility of dehydration, especially in elder-
ly persons; this could be a reason to insist that the patient
at least drink water.
CONCLUSION
It has been my experience that the overwhelming
majority of patients with either type 1 or type 2 diabetes
can, from the perspective of blood glucose control, safely
fast on Yom Kippur or one of the other Jewish fast days.
In the absence of any previously published guidelines, I
have outlined my approach to adjusting the currently
available hypoglycemic agents, with the main objective
being to avoid hypoglycemia. I have described several
concepts that should help clinicians advise patients when
new hypoglycemic agents become available. Finally, I
would recommend that clinicians be proactive and, in the
fall of the year, ask their Jewish patients with diabetes if
they would like to discuss changes in their medication sur-
rounding Yom Kippur. This discussion would prevent the
patient from relying solely on personal judgment and pos-
sibly taking too much medication, with the resultant devel-
opment of hypoglycemia. It also would send a message to
patients, who might be hesitant to ask, that fasting on Yom
Kippur is something that can be done safely.
ACKNOWLEDGMENT
I thank Rabbi Mordechai Willig, Rabbi of Young
Israel of Riverdale, Bronx, New York, and Professor of
Talmud at Yeshiva University, New York, New York, in
general for his ongoing advice on religious issues that I
encounter in my medical practice and in particular for his
review and assistance in preparing this manuscript.
DISCLOSURE
The author has no conflicts of interest to disclose.
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