The Pesach Seder is arguably the quintessential ritual experience in Judaism. From the mitzvot of the Seder, like drinking the four cups of wine, eating the matzah and marror (bitter herbs,) and reciting the Hagadah, to the traditional songs and unique family customs, the entire Seder experience is hopefully one of excitement, enjoyment, and great spiritual meaning.
But for many, it can also be a time of worry, fear, and even potential risk. Hundreds of thousands of Jews across the world suffer from serious gastrointestinal diseases, with the incidence of many of them continuing to rise. In October, 2017, an article published in “The Lancet” assigned Inflammatory Bowel Disease, IBD, (Crohn’s Disease and Ulcerative Colitis) the status of a global disease. An article published in “The Scientist” last year titled “The Celiac Surge” noted the increasing rates of celiac disease. And not only are many of these GI diseases quite common in Jews, particularly of Ashkenazi descent, but they are also, unfortunately, quite common in young adult and even pediatric age groups.
These ailments are challenging year round, but become particularly acute during Pesach, when diets are thrown out of routine, and certain foods are not only eaten, but consumed in quantities that can even rile normal gastrointestinal tracts.
In Celiac Disease the presence of gluten causes the immune system to, in essence, attack the lining of the small intestine, rendering it unable to absorb nutrients. Patients can experience abdominal pain, diarrhea, weight loss, anemia and malnutrition. If left untreated, it can even lead to infertility and some forms of cancer. The only treatment is complete avoidance of all gluten. Even minimal exposure to any gluten can cause serious symptoms.
Inflammatory Bowel Disease (Crohn’s Disease and Ulcerative Colitis, UC) is marked by the immune system causing inflammation in various areas of the GI tract (Crohn’s can occur anywhere; UC is limited to the colon). Patients can experience rectal bleeding, diarrhea, severe pain, as well as narrowing or even blockage of the GI tract. IBD also can predispose patients to cancer. Though the exact trigger is unknown, and no exact diet link is proven, many IBD patients report difficulty digesting gluten, dairy and alcohol, among many other foods.
Irritable Bowel Syndrome (IBS) is different than IBD and Celiac disease, as it is more a functional disorder of GI motility. But for those with IBS, simple alterations in diet can cause significant symptoms.
Pesach can, therefore, be a particularly difficult time for people with these diseases. While alternative matzah options now exist, for many, significant issues remain. Many erroneously think spelt matzah is gluten-free. It isn’t. Though the gluten protein in spelt is more water-soluble and more easily digested by some, it still contains gluten and therefore, is not an option for those with celiac disease or IBD patients who are very sensitive to gluten. Oat matzah, though gluten-free, can still be difficult for many patients with GI issues because of the fiber content. In addition, there are potential halachic issues with oat matzah at the Seder as oat flour is usually heated before storing, which makes it unable to become chametz. Since true matzah must have the ability to turn to chametz (Talmud Pesachim 39b), many authorities hold that oat matzah should be avoided at the Seder. Many people with chronic GI conditions also have difficulty with alcohol and sharp or spicy foods, making other aspects of the Seder difficult as well. And it’s not as if once the Seder ends all is easy for the GI patient. The rest of Pesach can still present significant challenges to the patient with a chronic GI condition.
It is well beyond the scope of this article to discuss what those with serious gastrointestinal diseases can or should do at the Seder and throughout Pesach. However, as every patient is different, it is imperative that not only should those with any health concern talk with both their doctors and their rabbis, but they should ask their doctors and rabbis to talk to each other. Far too infrequently do halachic and medical experts actually talk to one another to discuss patient-specific issues. Patients should never be afraid to simply ask their doctor “can you please talk to my rabbi?” or ask their rabbi, “can you please talk to my doctor?” Patients are usually neither medically trained nor halachic experts, and for them to be the go-between can lead to misinformation and sub-optimal decision making.
But beyond the halachic and medical details, it is important to bring awareness to the fact that those with gastrointestinal diseases can also find themselves isolated and lonely. While everyone at a festive meal is chomping away, they are forced, at best, to eat alternative foods. Moreover, I have personally witnessed the naïve and insensitive (albeit unintentional) remarks made to those who are forced to deal with chronic gastrointestinal disease. “Oh, a little bit couldn’t hurt- here, just take one bite.” “I know what you are going through- my stomach hurt last week as well.”
The Seder night is no doubt different from all other nights. But for the many Jews who suffer from chronic gastrointestinal diseases, the difference will be even greater. To all of those patients, I urge you to speak to your doctors and rabbis and have them speak to each other as well. To all others, please be mindful and sensitive to those at your table. And then hopefully, everyone’s gut, will truly have a “gut” yom tov.