Fasting for Patients with Crohn's Disease and Ulcerative Colitis - Medical and Religious Perspectives
Professor Dan Turner, Director of the Center for Crohn's and Colitis in Children and the Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, and Head of the Crohn's and Colitis Department at "Kamoni".
Rabbi Gavriel Goldmann, Community Rabbi of Kfar Adumim
For individuals diagnosed with inflammatory bowel diseases such as Crohn's disease and ulcerative colitis, fasting, as a general rule, is permissible in terms of the inflammation itself. Moreover, Crohn's disease of the small intestine often responds positively to periods of nutritional rest, where food intake is temporarily suspended, and the gut is given a chance to rest. Rarely do we resort to this treatment during hospitalization for severe and persistent disease. However, it's important to note that in such cases, unlike regular religious fasting, we provide the patient with nutrition through intravenous feeding, ensuring that the body still receives full caloric and nutritional requirements.
Thus, a patient diagnosed with inflammatory bowel disease, in a stable nutritional condition, with normal blood tests, and feeling healthy, can generally fast under the guidance of the treating physician and based on individual circumstances. In cases where a doctor's instruction advises against fasting, this religious requirement must be followed. Consideration should be given to the continuation of regular medication, as some medications cannot be taken on an empty stomach. If medication cannot be postponed until after the fast, a small meal should be eaten before taking the medication.
Another aspect to consider when deciding about fasting with inflammatory bowel diseases is the type of fasting. Yom Kippur fasting is the most stringent, being a biblical requirement. Then comes Tisha B'Av, followed by the regular fast days (10th of Tevet, 17th of Tammuz, Fast of Esther, and Fast of Gedaliah), which are considered less stringent from a religious perspective. The Fast of Esther is even lighter. The difference between Yom Kippur and Tisha B'Av for patients is that on Yom Kippur, one is allowed to eat only under the circumstances of danger to life or potential danger to life, while on Tisha B'Av, patients are not obligated to fast and are allowed to eat and drink even without a potential danger to life. On regular fast days, patients are generally exempt.
From a religious perspective, patients who cannot fast can, in certain cases, engage in "eating and drinking small amounts." This means consuming less than a "shiur" – the quantity defined by Jewish law for food and drink – and having a pause between eating and between drinking. This is required only on Yom Kippur. On Tisha B'Av (and certainly on regular fast days), according to the opinion of most halachic authorities, patients who are allowed to eat can eat normally and do not need to eat in small amounts. However, it is customary to consume simple, nourishing foods and avoid indulgent treats, including meat and wine. In terms of drinking, a "shiur" is defined as an amount of liquid equal to the volume of one cheek-full. An "average person" is estimated to consume about 40 cc of liquid in a single sip. Concerning "pausing," halacha allows consuming and drinking an amount less than a "shiur" within 4-9 minutes, according to different halachic approaches.
In any case, a doctor's opinion should be sought, as there are situations where fasting may not be advisable. For example:
• Fasting is not recommended during an active illness. Even those with a clinically mild active illness (such as symptoms of diarrhea, abdominal pain, etc.) require extra caution if laboratory tests are abnormal (such as elevated inflammation markers in blood or stool or a decrease in blood protein levels) even in the presence of clinical stability.
• In a non-active illness accompanied by a feeling of weakness (resulting from iron or vitamin deficiency or after surgery), full fasting may exacerbate the feeling and even lead to fainting.
• In cases of malnutrition or after surgery, concentrated efforts are needed to address deficiencies and regain weight. In such cases, fasting may delay healing even if the disease is in remission.
• The use of medications that cannot be postponed after fasting and require intake on a full stomach renders complete fasting infeasible.
General Recommendations:
• On the day preceding the fast and especially during the final meal, it is recommended to consume complex carbohydrates with a low glycemic index and to stay well-hydrated. Fermented beverages and alcohol are not recommended.
• During the fast, pay attention to unusual symptoms and listen to your body. If weakness or unexpected symptoms arise beyond what's anticipated, eat and drink immediately and seek medical attention. We emphasize not only the supervision of life-threatening conditions but also situations of potential concern, even on Yom Kippur or during the more lenient fasts.
• At the end of the fast, it is recommended to gradually eat and not overwhelm the digestive system.