ORIGINAL PAPER

Jewish New Year associated with decreased point of care

glucose in hospitalised patient population
J. Wainstein,1 Z. Landau,1 Z. Matas,2 T. Chaimy,2 M. Boaz3,4

SUMMARY

Whats known

Background: In individuals with diabetes, glycaemic control has been shown to

be disrupted during the winter holiday period. Objectives: The aim of this study
was to examine whether blood glucose levels are influenced by the Jewish New
Year period in hospitalised individuals with diabetes. Methods: At E. Wolfson
Medical Center, Holon, Israel, blood glucose values from individuals hospitalised in
internal medicine units were collected and analysed during the period surrounding
Rosh Hashanah, the Jewish New Year, 2010. Values obtained from 4 to 7 September 2010 were categorised as preholiday values; values from 8 to 11 September
2010 were classed as holiday values; and values from 12 to 15 September 2010
were labelled postholiday values. All values were collected at point of care (POC)
using an automated, institutional glucometer located in each department, the data
from which is downloaded to a central database. Results: A total of 3403 POC
glucose values were recorded during the observation period. POC glucose values
were significantly lower during the Rosh Hashanah holiday than the pre holiday or
postholiday periods: 176.8 81.3 mg dl vs. 181.4 78.8 mg dl or
184.9 83.02 mg dl, p = 0.03. During the Rosh Hashanah holiday, mean patient
age was significantly older than the preholiday or postholiday period: 77.4 10.9
years vs. 74.9 12.0 years or 75.3 11.8 years, p < 0.0001; however, age predicted less than 1% of the variability in POC glucose: r = 0.02, p = 0.23. Significantly more women were hospitalised during the preholiday than during the
holiday or postholiday periods. In a linear regression model, holiday period
remained a significant independent predictor of POC glucose even after controlling
for age and gender. Conclusions: Point of care glucose was significantly lower
during the Rosh Hashanah period relative to preholiday and postholiday values.
This may reflect a shift in the composition of the hospitalised patient population
during the holidays towards older individuals with more restricted dietary intake.

Background
Holidays may pose glucose management challenges
for individuals with diabetes. Religious fasts, for
example, have received attention because of the risk
of hypoglycaemia, especially in patients receiving
intensive insulin therapy or sulfonylureas (1). Both
the 25-h Yom Kippur fast and the shorter Ramadan
fast require careful blood glucose monitoring and
medical counselling regarding medication timing and
dose (1,2).
Feast holidays, on the other hand, may lead to
hyperglycaemic excursions. In a study of glycaemic
control during the Christmas holidays, a preholiday
increase in fructosamine persisted during the holiday

To date, a number of articles have identified an

increase in glucose, HbA1c or fructose surrounding
holiday periods, suggesting increased dietary intake
associated with glucose excursions. These studies
report on community-dwelling populations.

Whats new
This is the first report of the effect of holidays on
blood glucose in hospitalised patients. The direction
of the glucose pattern surrounding the holiday
period is contrary to the authors hypothesis.

Diabetes Unit, E. Wolfson

Medical Center, Holon, Israel
Biochemistry Laboratory,
E. Wolfson Medical Center,
Holon, Israel
3
Epidmiology and Research
Unit, E. Wolfson Medical
Center, Holon, Israel
4
Department of Nutrition,
School of Health Sciences, Ariel
University Center, Ariel, Israel
2

Correspondence to:
Dr Mona Boaz, Epidemiology
and Research Unit, E. Wolfson
Medical Center, Holon 58100,
Israel
Tel.: + 972 52 475 4658
Fax: + 972 3 502 8384
Email: mboaz8@yahoo.com
Disclosure
None.

season and decreased during the postholiday period

(3). This pattern of preholiday fructosamine increase
followed by a postholiday decline was similarly
observed surrounding the Chinese New Year holidays
(4). To control for seasonal climate variation, HbA1c
was measured in tropical Singapore and the circannual HbA1c pattern was observed to be correlated
with the number of festivals in the preceding
3-month period (5). Consistent with this finding,
HbA1c levels were observed to peak immediately following both the Christmas and Easter holidays (6).
Although the energy content of hospital-prepared
meals does not increase during Rosh Hashanah (it is
approximately 2000 kcal day throughout the year
for a standard diet), we assumed that the holiday

2011 Blackwell Publishing Ltd Int J Clin Pract, October 2011, 65, 10, 10551058
doi: 10.1111/j.1742-1241.2011.02707.x

1055

1056

Jewish New Year hospital glucose levels

tradition of consuming apples and honey, together

with the custom of bringing gifts of food, would lead
to an increase in energy intake in hospitalised
patients. Thus, we hypothesised that glucose values
would be elevated during Rosh Hashanah (the Jewish
New Year) relative to the immediate preholiday and
postholiday periods in hospitalised patients.

Methods

Results of POC glucose were extracted from the

central laboratory database by laboraotry personnel,
without personal identifier for a given patient. Thus,
data extraction was retrospective, although the study
design is cross-sectional. As such, informed consent
was not required.
Point of care blood glucose values were downloaded from the database to spreadsheet for analysis.

Data analysis

Objectives
This study was designed to compare POC blood glucose values in hospitalised patients with diabetes during the 4-day Rosh Hashanah holiday period to
those obtained during the 4 days preceding the holiday and the 4 days following the holiday.

Setting, data collection and definitions

All POC glucose values obtained from adult
(> 18 years of age) patients hospitalised in internal
medicine units at The Edith Wolfson Medical Center, a 700-bed government hospital which serves
approximately 500,000 residents of the area south of
Tel Aviv, were included in the analysis. Since 2007,
this hospital has utilised an institutional blood glucose monitoring system (IGMS) in the framework of
its Program for the Treatment of the Hospitalized
Diabetic Patient (PTHDP). Previously described in
detail (7), the PTHDP is a hospital-wide care protocol based on the American Diabetes Association
Standards of Medical Care in Diabetes 2007 (8) and
includes insulin treatment protocols, a multi-disciplinary specialty care team which provides expert
consultations for inpatient units and extensive discharge planning for continuity of care.
The IGMS consists of a POC, automated glucometer, and an interactive database. The automated glucometer (Accu-Check Inform, Roche Diagnostics,
Indianapolis, IN, USA), is located in each inpatient
department. Data are automatically transmitted and
downloaded to the central database of the hospitals
Biochemistry Laboratory. All blood glucose values in
the present report were obtained using the IGMS.
The study periods were defined as follows: values
from 4 to 7 September 2010 were categorised as preholiday values; values from 8 to 11 September 2010
were categorised as holiday values; and values from
12 to 15 September 2010 were comprised the postholiday values. Dates were defined as beginning at
12:01 h of that day and ending on 23:59 h of the
same day. POC glucose is routinely measured prior
to breakfast, between 07:00 h and 08:00 h; prior to
dinner, between 17:00 h and 18:00 h; and prior to
bedtime, between 21:00 h and 22:00 h and timing is
not altered on holidays or weekends.

Data were transferred from the IGMS-generated

database and analysed on spss 10.0 (SPSS Inc.,
Chicago, IL, USA). Normality of distribution was
assessed using the KolmogorovSmirnov test. Glucose and age had distributions significantly deviating
from normal. Continuous variables are described as
mean standard deviation. Nominal variables are
described using frequency counts and are presented
as n (%). Glucose and age were compared across
observation periods (preholiday, holiday and postholiday) using the KruskalWallis test followed post
hoc by the MannWhitney U-test. Associations
between continuous variables were described by the
Spearmans correlation coefficient. Associations
between nominal variables were assessed using the
chi-square test. A multiple linear regression model of
glucose was developed including holiday vs. non-holiday, age and gender as covariates. All tests are twosided and considered significant at p < 0.05.

Results
A total of 3403 POC glucose values were recorded
during the entire observation period: 1205 in the
preholiday period, 1006 in the holiday period and
1192 in the postholiday period.
The study population is described in each of the
observation periods in Table 1. As can be seen, POC
glucose values differed significantly across observation periods. Post hoc analysis demonstrated that values were significantly lower in the holiday period
than either the preholiday (p = 0.02) or postholiday
(p = 0.01) periods, but that preholiday and postholiday POC glucose values were similar (p = 0.69).
Age also differed significantly across observation
periods, and was significantly older during the holiday period than either preholiday (p < 0.0001) or
postholiday (p < 0.0001) periods; age did not differ
significantly between the pre- vs. postholiday period
(p = 0.62). Despite these differences, age predicted
less than 1% of the variability in POC glucose OC
glucose r = 0.02, p = 0.23.
An across-observation period difference in the
proportion of females was observed, driven by the
significantly greater proportion during the preholiday

2011 Blackwell Publishing Ltd Int J Clin Pract, October 2011, 65, 10, 10551058

Jewish New Year hospital glucose levels

Table 1 Characteristics of the study population by observation period

Glucose (mg dl)

Age (years)
Gender (% females)

Preholiday
(September 47)
n = 1205

Holiday
(September 811)
n = 1006

Postholiday
(September 1215)
n = 1192

p-value

181.44 78.8
74.9 12.0
56.6

176.8 81.3
77.4 10.9
47.8

184.9 83.02
75.3 11.8
46.1

0.03
< 0.0001
< 0.0001

period than either the holiday (p < 0.0001) or postholiday (p < 0.0001) periods; however, the proportion of females during the holiday and postholiday
periods did not differ significantly (p = 0.4). POC
glucose did not differ significantly by sex and was
182 84.3 mg dl in women vs. 180.2 77.7 mg dl
in men, p = 0.41.
Observation period was dichotomized into holiday
vs. non-holiday period. Characteristics of the study
population by this factor are shown in Table 2.
Patients hospitalised during the holiday period had
significantly lower POC glucose and were significantly older than patients hospitalised during the
non-holiday period. Somewhat fewer women were
hospitalised during the holiday than non-holiday
period, but the difference was not statistically significant.
In univariate analysis, holiday significantly, inversely predicted POC glucose: standardised beta =
)0.036, p = 0.04. A multiple linear regression of
POC glucose is shown in Table 3. As can be seen,

Table 2 Characteristics of the study population by

holiday
Holiday
n = 1006

Non-holiday
n = 2397

p-value

Glucose (mg dl)

176.8 81.3 183.2 80.9
0.01
Age (years)
77.4 10.9 75.1 11.9 < 0.0001
Gender (% females)
47.8
51.4
0.06

Table 3 Multiple linear regression model of POC

glucose

Constant
Holiday (Rosh Hashanah vs.
non-holiday)
Age (years)
Gender

Standardised
beta

p-value

)0.04

< 0.0001
0.03

0.02
)0.01

0.19
0.51

holiday period emerged as significant, independent,

inverse predictor of POC glucose. Age and gender
did not significantly predict POC glucose.

Discussion
Contrary to our expectations, holiday period was significantly inversely associated with POC glucose. This
finding persisted even after controlling for age and
gender. Although statistically significant, this 3.5%
relative decline in POC blood glucose may not be
clinically meaningful; nevertheless, that values did
not increase during the holiday period is surprising,
especially in view of the literature.
Establishing the decline in POC glucose as a true
decline and not simply measurement error is essential. Hospital protocol requires continuous calibration of the glucometer and no change in glucometer
or laboratory equipment occurred during the study
period. This suggests that the observed decline in
POC glucose is not attributable to measurement
error and is in fact a real decline. A true decline in
POC glucose may reflect increased physical activity
or decreased dietary intake. It seems quite unlikely
that hospitalised patients would spontaneously
increase their physical activity. This means that the
most likely explanation is a decline in dietary intake.
The patient population composition changed during the holiday period, Importantly, the population
size decreased by 16.5% relative to the preholiday
period, but a 30% reduction from preholiday proportion of females was observed concomitantly. This
suggests a selective discharge and or lack of new hospitalisations for females during the holiday period.
The reason for the shift in the gender distribution of
the hospitalised patient population during the holidays was not directly investigated. It can be postulated that female patients may have taken advantage
of a holiday furlow from hospitalisation to a greater
extent than males, perhaps responding to traditional
female roles of preparing the holiday; however, this
information is not recorded in the central database.
Point of care blood glucose measures in this
study were not limited to fasting values. As such,

2011 Blackwell Publishing Ltd Int J Clin Pract, October 2011, 65, 10, 10551058

1057

1058

Jewish New Year hospital glucose levels

differences in dietary intake would be expected to

influence POC glucose values. It is precisely for this
reason that we hypothesised that POC glucose would
be elevated during the holiday period. Increased food
intake during the holiday period is both intuitive
and has been documented in the literature (9),
although has not been addressed in hospitalised individuals. In this study, patients were served essentially
identical meals and these meals were isocaloric during holiday and non-holiday periods. Dietary intake
was not recorded, however, so its influence on outcome cannot be directly observed. It is possible that
individuals remaining in the hospital during the holiday in fact consumed less food than they would have
otherwise, perhaps because of emotional stress. Stress
has been shown to trigger reduced milk intake in an
animal model of depression (10) and a large proportion of hospitalised patients have been reported to
consume less energy than determined as necessary in
the nutrition care plan (11). This may explain the
unexpected decline in holiday POC glucose values.

References
1 Katz Y, Zangen D, Leibowitz G, Szalalt A. Diabetic
patients in the Yom Kippur fast who can fast an
dhow to treat the fasting patients. Harefuah 2009;
148: 58991 (Hebrew).
2 Al-Khawari M, Al-Ruwayeh A, Al-Doub K, Allgrove
J. Adolescents on basal-bolus insulin can fast during
Ramadan. Pediatr Diabetes 2010; 11: 96100.
3 Chen HS, Jap TS, Chen RS, Lin HD. A prospective
study of glycemic control during holiday time in
type 2 diabetic patients. Diabetes Care 2004; 27:
32630.
4 Chen HS, Wu TE, Jap TS, Chen RL, Lin HD.
Effects of health education on glycemic control during holiday time in patients with type 2 diabetes
mellitus. Am J Manag Care 2008; 14: 4551.

Subjects hospitalised during the holiday period

were significantly older than those hospitalised during either of the other two periods; however, age was
not significantly associated with POC blood glucose
and explained little of its variability (less than 1%).
Nevertheless, almost half of hospitalised older persons have decreased appetite (12), and this may be
reflected by reduced dietary intake. Indeed, ageing
has been associated with reduced food intake which
may result in inadequate intakes of energy and some
nutrients (13).
This study identifies an unexpected decline in
POC blood glucose in adult patients hospitalised
during the Rosh Hashanah holiday compared with
the immediate preholiday and postholiday periods.
The observation may reflect a shift in the composition of the patient population during the holiday
period towards older individuals who perhaps exhibit
more restricted dietary intake.

5 Hawkins RC. Circannual variation in glycohemoglobin in Singapore. Clin Chim Acta 2010; 411: 18
21.
6 Gikas A, Sotiropoulos A, Pastromas V, Papazafiropoulou A, Apostolou O, Pappas S. Seasonal variation in fasting glucose and HbA1c in patients with
type 2 diabetes. Prim Care Diabetes 2009; 3: 1114.
7 Boaz M, Landau Z, Matas Z, Wainstein J. Institutional blood glucose monitoring system for hospitalized patients: an integral component of the
inpatient glucose control program. J Diabetes Sci
Technol 2009; 3: 116874.
8 American Diabetes Association. Standards of
medical care in diabetes 2007. Diabetes Care 2007;
30(Suppl. 1): s441.
9 Munnelly P, Feehan S. An obesity clinic model.
Proc Nutr Soc 2002; 61: 910.

10 Enkel T, Spanagel R, Vollmayr B, Schneider M.

Stress triggers anhedonia in rats bred for learned
helplessness. Behav Brain Res 2010; 209: 1836.
11 Schindler K, Pernicka E, Laviano A et al. How
nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients findings
from the 20072008 cross-sectional nutritionDay
survey. Clin Nutr 2010; 29: 5529.
12 Mowe M, Bohmer T. Reduced appetite. A predictor
for undernutrition in aged people. J Nutr Health
Aging 2002; 6: 813.
13 Zhu K, Devine A, Suleska A et al. Adequacy and
change in nutrient and food intakes with aging in a
seven-year cohort study in elderly women. J Nutr
Health Aging 2010; 14: 7239.
Paper received January 2011, accepted April 2011

2011 Blackwell Publishing Ltd Int J Clin Pract, October 2011, 65, 10, 10551058

Copyright of International Journal of Clinical Practice is the property of Wiley-Blackwell and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.