Eating disorders are a unique and challenging set of mental illnesses that impact about 4% of the U.S. population. Anorexia Nervosa (AN) has the highest mortality rate of any mental illness. In fact, it is estimated that individuals with AN have a six-fold increase in mortality risk than that of the general population. A devastating disease that does not discriminate against age, race, class, gender, sexual orientation, or religion, AN needs immediate evidence-based treatment.
Orthodox Jews are not immune to eating disorders. In fact, there are some estimates that the rates of eating disorders among Orthodox teenagers is close to double that of the national average. Israel, a country that is 75% Jewish, has one of the highest per capita rates of eating disorders. Efficacious treatment for Orthodox Jews needs to be culturally sensitive and may need to address several unique cultural and/or religious factors. For the sake of clarity and simplicity, this article will address Orthodox Jewish individuals as adhering to most of the same religious principles, though clinicians should be aware that diverse levels of religiosity and stringency exist among those who identify as Orthodox.
A crucial component of any treatment for AN is the daunting task of weight restoration through a process called renourishing (sometimes referred to as refeeding). Depending on the severity of AN, renourishing can be done in a hospital, residential, outpatient or home setting. Orthodox Jews may face specific challenges in areas related to renourishing and these challenges need to be dealt with sensitively and creatively.
Pikuach Nefesh (Saving a Life) Takes Precedence
While a lot of Orthodox life is proscribed and law-bound, the good news is that Jewish law also prioritizes the principle of pikuach nefesh, the saving of one’s life, over adhering to other demands of Jewish law. This essentially means that nearly all Jewish laws are secondary to risks that are life-threatening. If for example, an Orthodox mother has a heart attack on Shabbat (a day that Orthodox families do not drive or use the phone), because of the principle of Pikuach Nefesh, the woman’s family MUST break Shabbat by using the phone, dialing 911 and transporting the patient to the hospital for life saving help. Because eating disorders are medical threats to mortality, there is often room, even for strict Orthodox individuals, to override many principles of Jewish law due to the dictate of Pikuach Nefesh.
Some Orthodox individuals will choose to use the principles of pikuach nefesh on their own to make decisions about feeding that may seem to contradict Jewish law. Many individuals, however, will want to consult with their rabbi to receive guidance about the extent to which they can or should be lenient. Orthodox individuals should consult with a rabbi who is well-versed in both mental illness and eating disorders. Therapists can also serve as powerful liaisons and advocates for patients by consulting with their Rabbis when applicable. The Jewish law(s) in question should be explained fully, including the short-term and long-term risks of prioritizing a particular Jewish law over the renourishing process, and vice versa.
Areas of Jewish law that may impact the renourishing process for a patient with anorexia nervosa encompass kosher dietary laws, ritual fast days, Passover food restrictions and other laws related to food and eating.
First, let’s address what it means to “keep Kosher.” Jews who keep kosher can eat chicken, cows, turkey, and some species of fish, but cannot eat pork and shellfish. The kosher animals must be ritually slaughtered, cleaned, and require a kosher symbol or stamp. Fruits, vegetables, and eggs are kosher, but grains and dairy products must be cooked and/or prepared in specific ways, necessitating proper certification on the packaging. Kosher law also dictates that meat and dairy products must not be eaten together, prohibiting foods like pepperoni pizza and cheeseburgers. In fact, there is a waiting period after consuming meat during which an Orthodox Jew cannot consume dairy; the number of hours they must wait depends on the tradition of the family. It is not uncommon for families to wait five or six hours after meat in order to consume dairy. The restriction does not typically work the other way (for example, after drinking a glass of milk, Orthodox Jews can eat a steak 20 minutes later without needing to wait any period of time).
Some practical tips for families and/or clients who keep kosher are as follows:
- Find a competent and understanding rabbi who is familiar with mental illness and eating disorders. This can mean all the difference when it comes to successful renourishing. A rabbi who fully understands the severity of anorexia nervosa may suggest eliminating or reducing the patient’s wait time between meat and milk. Trust your instincts as well. If you choose to involve a rabbi, work with him (and perhaps involve your therapist) until you come up with solutions that feel right to all of you.
- As a kosher consumer, you may not have the flexibility to pick up meals wherever you are. You will need to plan ahead if you intend to be away from home during a meal or a snack time. Keep a handful of calorically dense foods on you (such as nuts, chocolate bars, packets of nut butters, etc.) in case you are ever stuck.
- It is not uncommon for patients to add butter or heavy cream to foods in order to increase the caloric density of foods. Orthodox Jewish patients do not have the luxury of adding butter or cream to every meal as they are dairy additives that cannot be eaten with meat. For meat meals, in which adding butter is not an option, use alternative oils, such as canola, avocado, or coconut. Coconut oil actually has more calories per tablespoon than butter, and refined coconut oil does not have a coconut taste or smell. Some kosher individuals find that they eat more dairy meals during the process of renourishing so as to avoid the issues associated with eating meat, but be careful that avoiding meat does not become an eating disorder symptom. For most people, it might be better not to eliminate meat altogether, but rather try to save meat for dinners, after which it is less likely you will want a dairy meal or snack to follow.
- Milkshakes or muffins can be made non-dairy using non-dairy ice cream, non-dairy whipping cream, and coconut oil. Check the calorie and fat contents of non-dairy items — you can often find ones that are as calorically dense as their dairy equivalents.
- If hospitalization or residential treatment become necessary, don’t allow a lack of kosher food to be a deterrent. Consult with your rabbi. Most will prioritize quality of treatment over the kosher status of the food. For individuals who receive inpatient treatment, it is important for treatment teams to understand ahead of time where the patient falls on the religious spectrum and to which laws he or she is committed. Clarity on these issues can help treatment teams differentiate between actual religious observance versus eating disorder symptomatology.
In addition to laws around kosher food, there are other aspects of Orthodox Jewish life that may be challenging to navigate during AN treatment. Orthodox Jews are Sabbath-observant. Shabbat (or Shabbos) is a 25-hour period of rest that starts at sunset every Friday and ends at nightfall on Saturday. There are multiple celebratory meals that occur over Shabbat (think Thanksgiving-type meals with multiple courses). Shabbat is usually a time of communal socialization, and Shabbat meals often include guests or extended family members. Eating Shabbat meals may pose additional challenges for the Orthodox patient due to the types of foods served, the communal/familial structure of the meal, and their often unpredictable nature. Patients may need to make modifications for awhile, such as eating Shabbat meals with only intimate family members, asking parents or a trusted friend to plate their food to avoid having to deal with the buffet-type serving style typical of Shabbat meals, or even eating separately initially.
Another hallmark of Shabbat observance is the deliberate avoidance of technology. For an individual with an eating disorder, this could pose an extra challenge if he or she relies on technology for support with eating disorder symptomatology. For example, consider the case of a child who watches her favorite TV show after meals to distract herself from the urge to purge, or the college student who skypes with her mother for meal support. Families and individuals will need to make decisions about technology use on their own or with a trusted rabbinical and therapeutic support.
Another issue that is relevant to eating disorder treatment for Orthodox Jews is ritual fast days. The Jewish calendar contains 6 fast days throughout the year, The most well- known fasts are Yom Kippur and Tisha Ba’av. These are 25-hour fasts that begin at sundown and end at sundown the following day. Orthodox individuals refrain from both eating and drinking on these days. There are also four shorter (dawn to sundown) fast days scattered throughout the year; to many, the shorter fasts are less essential to follow than the two major fasts.
Individuals with eating disorders often struggle on fast days, and even the thought of fasting might be triggering for some. Patients will need to weigh the pros and cons of fasting with their treatment team and if desired, their Rabbinic authority. During the process of renourishing, most competent Rabbis would forbid observing most or all fast days in the name of pikuach nefesh. If the decision is made that a patient will be eating on a fast day or otherwise deviating from Jewish tradition, great care should be taken to preserve the patient’s religious dignity. That might mean finding alternate meaningful ways to commemorate the fast. For patients who are struggling, this might mean having their rabbi reassure them that their spiritual work of the day is to prioritize treatment and that this is a God-sanctioned endeavor. There is a prayer found in some Yom Kippur prayer books that some patients might find meaningful to recite before eating on a fast day: Behold I am prepared to fulfill the mitzvah of eating and drinking on Yom Kippur, as You have written in Your Torah: “You shall observe My statutes and My ordinances, which a man shall do and live by them. I am the L-rd.” In the merit of fulfilling this mitzvah, seal me, and all the ill of Your nation Israel, for a complete recovery. May I merit next Yom Kippur to once again fulfill [the mitzvah of] “you shall afflict yourselves [on Yom Kippur].” May this be your will. Amen.
Passover, an eight-day holiday that falls in the Spring, celebrates the Jewish exodus from Egypt. This long holiday may also pose some challenges to the Orthodox patient in the renourishing process. During Passover, products that are made or derived from wheat, barley, rye, oats, or spelt and have come into contact with water and been allowed to ferment and rise, are prohibited. This translates to most breads, baked goods, and cereals. Many Jews also refrain from consuming rice and legumes during this period.
Before Passover, most families scour their kitchen to eliminate any traces of these foods and use a separate set of dishes and pots to cook for this holiday. The first two nights of Passover include a Seder, which is a relatively long ritual meal with specific food and drink requirements. The Seders can be a source of stress for a patient in recovery, and he or she may need to adjust the ritual requirements with a rabbi and/or therapist and attend Seders surrounded only by a few close supports so as not to risk recovery. There may be special dispensations that are necessary in order to ensure that Orthodox patients can continue eating appropriate amounts of calories on Passover. For example, patients may decide to eat rice and legumes on Passover (typically a food that only some Sefardic Jews eat on Passover; these are foods that most Ashkenazic Jews avoid on Passover). Patients may also decide to eat things made with derivatives of foods they typically avoid on Passover. For example, corn is a legume avoided by many Jews on Passover. Patients with AN may decide to eat products that contain corn syrup (such as some brands of ice cream) despite traditionally avoiding those foods on Passover. For those who uphold all stringencies, quinoa is considered kosher for Passover by most kosher consumers and can be used as a rice/pasta/starch substitute.
Orthodox Jewish life can be rich with meaning, tradition and community. At the same time, Orthodox patients who are in treatment for AN often struggle with challenges related to renourishing and weight restoration. For issues revolving around the circumvention of ever-important religious edicts, (whether one chooses to make those modifications alone or with the guidance of a competent Rabbi), it is empowering to know that patients do not have to choose between religion and treatment. With some forethought, creativity, and planning- patients can balance Judaism with successful nutritional rehabilitation and treatment of anorexia nervosa.
Accuracy of principles of Jewish law reviewed by Rabbi Jason Weiner, Senior Rabbi & Director of the Spiritual Care Department, Cedars-Sinai Medical Center
About The Author:
Elisheva Dorfman, MS, LMFT is a therapist in Los Angeles, California who specializes in evidence-based approaches to treating clients with eating disorders. She is trained in a variety of modalities including FBT (Maudsley) and CBT-E and she is also a Certified Intuitive Eating Counselor. She is passionate about dismantling diet culture and an advocate for Health at Every Size. She created and co-administrates a Facebook group called Intuitive Eating and Body Positivity for Jewish Women, the first group to bring these concepts to the Jewish community at large.
- National Eating Disorders Association (https://www.nationaleatingdisorders.org/mortality-and-eating-disorders)
- Ira Sacker, 1996 (http://www.tabletmag.com/jewish-life-and-religion/109958/orthodox-and-anorexic)
Written – 2017