Passover Guide for Diabetics
By Nechama Cohen/Jewish Diabetes Association

PESACH- HELP! Not the help we all scream about. This time it’s not the cleaning, getting organized, trying to figure out where to start and where to end. This time it’s diabetes! The challenge of diabetes seems ten-fold when it comes to Pesach. The whole routine changes! Four cups of wine at one meal! Hand matzoh. How do we know how many carbohydrates are in one hand matzoh?

These are real concerns for people with diabetes and related health issues that until now had few answers. After being inundated with questions of this nature, the staff at the Star-K turned to the Jewish Diabetes Association for guidelines. JDA has been answering these questions for thousands of affected individuals world wide for more than two decades, and has now written this article.

So how does one manage on Pesach without forfeiting the benefits of a healthy regimen and healthy lifestyle? Let us begin to address these issues.

Pesach does not necessarily have to mean matzoh, potatoes, and eggs throughout Yom Tov. Use your imagination. Instead of high fat soups load up on vegetables, and instead of potato kugel substitute other vegetables and vegetable combinations. Our book EnLITEned Kosher Cooking (available at most bookstores or online at www.jewishdiabetes.org) has more than 140 recipes for Pesach, and the rest are easily adaptable.

The following information will help you prepare your matzoh and wine. Remember that failing to prepare is preparing to fail. If you have everything ready you are less likely to run into problems.

MATZOH

The following is based on the psak of Rav Moshe Heinemann Shlit”a.Note: These calculations from the Star-K are based on the use of a Tzelem Pupa hand matzoh.

In The Case Of A Medical Condition One May Fulfill The Mitzvah Of Achilas Matzoh With The Following:

• Hand matzoh – one-sixth (1/6) of a matzoh. This is a piece of matzoh that is 13.75 sq in. in size.¹
• Machine matzoh – one-quarter (1/4) of a matzoh. This is a piece of matzoh that is 10.75 sq. in. in size.²

It should be noted that one who is in good health should eat the following for achilas matzoh:

• Hand matzoh – one-third (1/3) of a matzoh. This means a piece of matzoh that is 27.5 sq. in. in size.³
• Machine matzoh – one-half (1/2) of a matzoh. This means a piece of matzoh that is 21.5 sq. in.⁴

A. CALCULATING THE AMOUNT OF CARBS IN MATZOH:

Most machine matzoh is uniform in size and shape; the portion size and carbs are listed on the box. It might be a good idea to keep the amount that you intend to eat near your plate.

Hand matzoh varies according to size and thickness. Our calculations use a Tzelem Pupa hand matzoh. In order to simplify the calculations, we recommend that you weigh the matzoh before Yom Tov in order to become accustomed to the weight and sizes.

For those who prefer to do their own calculation, matzoh has an average carb factor of 0.75 (75% of its weight is carbohydrates). Whole wheat matzoh has almost 12 grams of dietary fiber per 100 grams, bringing down the total amount of carbs to almost 4 grams per slice. The more whole wheat products one uses throughout the year, especially during Pesach when there are so many meals, the more advantageous it is for most people..

Hand Matzohs: There are about 10 pieces of matzoh per lb. (22 pieces per kilo). Each piece weighs 46g and has 35g of carbs per matzoh. If we calculate 1/6 of a matzoh (the shiur specified above for one with a medical condition), it would amount to 6 g. of carbs for the shiur

Machine Matzos: One whole machine matzoh (rectangular) weighs about 28g which is between 23 and 27 g. of carbs per matzoh (depending on the brand).

B. PERFORMING THE MITZVAH OF ACHILAS MATZOH:

Achilas Matzoh, Korach, Afikoman – One who has a medical condition:

• Hand Matzoh (round): 1/6 of a matzoh = 6 gr. of carbs
• Machine Matzoh: 1/4 matzoh = 6 gr. of carbs

Achilas Matzoh, Korach, Afikoman – One who is in good health:

• Hand Matzoh: 1/3 of a matzoh = 12 gr. of carbs
• Machine Matzoh: 1/2 matzoh = 12 gr. of carbs

THE ARBA KOSOS (FOUR CUPS)

A. WINE: THE REQUIRED AMOUNT:

The cup must hold at least a reviis of wine (3.8 fl. oz., or 112 ml). Someone who has a medical condition should drink at least 1.5 fl. oz. (45 ml); someone who is in good health should drink at least 1.9 fl. oz. (56 ml).

One should not drink so much wine at the seder that he becomes drunk. The beverage used for the four cups must contain enough alcohol to be uplifting. However, he is not obligated to become sick because of this. The lowest percentage of alcohol that may be used for the four cups is 4%. He should drink each of the four cups of wine within half a minute.

B. ADDING WATER FOR WINE AND GRAPE JUICE:

Wine may be diluted in the following maximum ratios, while still retaining enough of its properties to qualify its usage for the four cups:

1/3 wine and 2/3 grape juice
1/3 wine and 1/3 grape juice and 1/3 water
1/3 wine and 2/3 water.

However, the diluted beverage must have at least 4% alcohol, in order to fulfill one’s obligation of drinking wine on Pesach.⁵ If necessary, one may make a mixture of 2/3 water and 1/3 wine (66% water and 34% wine) as long as the diluted amount still has 4% alcohol – otherwise there is a chance that it may no longer be considered wine.

If one follows these guidelines correctly, he will consume less than 3 fl. oz. of wine throughout the entire seder. In order to estimate the actual amount that he should drink at the seder, he should measure the exact amount that he will need before Yom Tov. He should choose the becher (kiddush cup) that he will be using at the seder and pour the measured amount into it so that he can recognize how much he will be drinking.

Here is an example of how to mix wine and water. Assume one has a wine with 10% alcohol content. If he makes a mixture of 40% wine and 60% water, he will have wine with 4% alcohol content which is enough for the arba kosos. This can be done by mixing two cups of wine with three cups of water. He could fill a becher that holds at least 3.8 fl. oz. and drink at least 1.5 fl. oz. (the amount one may drink to fulfill the mitzvah, when medically necessary). For the fourth cup, he could ask someone else to be motzee him in the bracha achrona. The following chart illustrates how much wine to drink.

Amount of drink		Amount of wine one drinks (after dilution)
First cup	1.5 oz.	0.6 oz.
Second cup	1.5 oz.	0.6 oz.
Third cup	1.5 oz.	0.6 oz.
Fourth cup	1.5 oz.	0.6 oz.
TOTAL	6.0 oz.	2.4 oz.

For the fourth cup, ask someone else to be motzee you in the bracha achrona.

In order to prepare in advance, simply pour 2 cups of wine into an empty bottle, and add 3 cups of water. (The size of the cup does not matter. Just make sure that you use the same cup for the water and the wine). It is always advisable to prepare this bottle in advance and label it as your own “SPECIAL RESERVE”.

C. TYPE OF WINE:

The best option would be a dry wine, which has almost no carbs. [Most dry wines contain approximately 4 grams of carbs per 8 oz. cup.] If the sour taste bothers you, try adding some artificial sweetener such as saccharin tablets which can be dissolved in water. Since the law does not require manufacturers to print nutrition facts on wine bottles, it is often hard to know exactly how many carbs a glass of wine contains. If you are trying to find a wine that is very low in sugar, you can use a glucose meter before Yom Tov to test a sample. (We tested it with a Glucometer Ascentia XL; not all meters will give accurate results).

Test a sample of the wine just as you would test a drop of blood on your meter. If the wine you are testing is a sweet wine, your meter will give you a HI reading. If it is a dry, low-carb wine the meter will read it as LO. Many of the dry wines will not give a LO reading, but the numbers are a very good reference. (Diabetes Forecast states that a cup of regular soda contains 4,500 mg/dl of sugar, which would give a very high reading. It pays to remember this so that you can keep the meter reading of a dry wine in proper perspective. By the way, this is a good way to test diet soda from fountains that could easily be interchanged with regular soda. To be certain that the soda you are drinking is really sugar-free, check it out on your meter.) For those who are not accustomed to drinking high quality dry wine, it may take some time to acquire a taste for it.

Here are some examples of wines we tested for sugar content on a glucose meter:

• Chardonnay was 225.
• Cabernet Sauvignon was 87.
• Sauvignon Blanc from Gamla was 27.

The above wines are only examples. Remember to test the specific wines that you are planning to use. Less expensive wines are rarely sugar-free. Checking on the meter seems to prove this statement, as some inexpensive supposedly dry wines actually tested HI on a meter.
Please note: Since alcohol may cause a drop in your blood sugar, discuss with your doctor whether or not to cover the carbs in the wine with insulin. There is more of a chance that wine will cause a low BG on an empty stomach. If you use pure (unmixed) wine for the first cup, make sure to follow the above guidelines and do not overdo your alcohol intake.

Those with Type 2 diabetes should discuss with their health care team and rav whether it is better to drink wine or grape juice. According to halachah, wine is preferable. Grape juice, with its high sugar content, is not ideal for those with diabetes. However, many of the oral medications used for treating Type 2 diabetes (non-insulin dependent diabetes) are not compatible with alcohol.

Therefore, we suggest showing the wine combination options to your health care team. As previously noted, after the dilution, the remaining alcohol content of all four cups is not significant. Many health care professionals have been very pleased with these dilution options and allow this small total amount of alcohol even with medication. Being able to participate in the seder with everyone else has a strong influence on normal quality of life. This is an important aspect when living with any long-term condition.

Those with gestational diabetes (diabetes in pregnancy) or T1, and who are pregnant, should check with their health care team and rav to determine which way to go. Again, show them the charts in order to guide them in their decision.

D. GRAPE JUICE

One should use wine or, if necessary, a wine/grape juice combination for the arba kosos. If one is unable to drink wine he may use grape juice instead. If due to medical reasons he is unable to drink pure grape juice for the arba kosos, (and cannot drink any percentage of wine), he may dilute the grape juice. When mixing grape juice with water, at least 50% of the mixture should be grape juice (e.g. the cup is half grape juice and half water). He may wish to prepare a “special reserve” mixture before Yom Tov and should fill a bottle with two full bechers of grape juice and two full bechers of water. This will suffice for the arba kosos. Keep in mind that as far as diabetes and carb counting are concerned, dry wine is certainly preferable. If he drinks grape juice, please note that the carbohydrate content of the various grape juices differs.

Those that we have researched range from 32-60g of carbs per cup. As previously noted, please make sure to check the label, in order to cut down the amount of carbs used in a combination of grape juice with wine and/or water.

Please note: Kedem’s Concord dark grape juice scored the lowest amount of carbs, 16 grams of carbs in a 4 oz. serving.

SUMMARY PREPARATION LIST

• Discuss with your Rav the shiurim of rov reviis and mixing wine with water.
• Select the wine of your choice and check the carb content (remember the meter test).
  Prepare the right size becher.
• Train your eye to recognize the amount that you will be drinking during the Seder.
  Mix the wine with water following the instructions of your Rav and doctor. Prepare a separate labeled bottle.
• Weigh matzohs in advance in order to be better prepared for deciding insulin doses.
• Make sure you have prepared in advance your choice of glucose for treating hypoglycemia.
• Review chart and details with your health care team.
• Prepare all medical supplies, medications and equipment for Yom Tov and Shabbos in advance l’kovod Yom Tov.

Other Products:

Today we are lucky to have a much larger variety of kosher for Pesach products. The following are some products with their nutrition facts.

Sugar Substitutes:

Sugar Substitutes (when label states Kosher for Pesach): Gefen brand Sweet’N Low, Paskez brand Sweetie, and Sucrazit brand are available. There may be others, but they must have specific Pesach supervision.

Powdered Equal, Splenda and Nutrasweet are NOT kosher for Pesach, and may not be used by Ashkenazim or Sefardim unless specifically noted.

It was once thought that products containing sugar, even in minute amounts, were totally off limits to people with or at risk for, diabetes and other related health conditions. However, the American Diabetes Association opposes totally restricting sugar, provided that it is consumed in the context of a healthy food choice. Therefore, foods with sugar listed as a lower ingredient on the label may be included in one’s meal plan, as long as they are counted in the appropriate food group. Sugar should be consumed in small amounts, and in most recipes may be cut down significantly and/or combined with sweeteners.

Common Cooking Ingredients:

Food	Amount	Carb.
Baking Powder	1 tsp.	2 gr.
	1 tbsp.	6 gr.
Choc. Chips	1 cup	105 gr.
Cocoa	1 tbsp.	2 gr.
Eggs	1 Large	0 gr.
Honey	1/2 cup	132 gr.
Matzoh Meal	1 cup	108 gr.
Potato Flakes	1 tbsp.	10 gr.
Potato Starch	1 tbsp.	8 gr.
Sugar	1/2 cup	64 gr.
	1 tbsp.	15 gr.

PESACH COOKIES AND CAKES

Below is just a partial list of the cookies and cakes that are available for Pesach. Most Pesach products are similarly manufactured and it is probably safe to assume that similar products will have more or less the same amount of carbohydrates. Since Pesach products are made from potato starch, sugar and/or matzoh meal they are all basically almost pure sugar. With enough preparation time, one should have no problem making his own snacks with fewer carbs. As always, the best way to go is good old fashioned “home made.”⁶

Product/Company	Serving size
Brownie Cake (Hagadda)	38 gr.	20 gr.
Chocolate Cake (Oberlander’s)	42 gr.	23 gr.
Rainbow Cake (Hagadda)	28 gr.	11 gr.
Sponge Cake (Oberlander’s)	42 gr.	24 gr.
Apricot Sandwich Cookies (Hagadda)	28 gr.	16 gr.
Leaf Cookies (Hagadda)	33 gr	14 gr.
Nut Cookies (Hagadda)	28 gr.	11 gr.
Raspberry Sandwich Cookies (Hagadda)	28 gr.	15 gr.
Chocolate Macaroons (Hagadda)	33 gr.	18 gr.

The following is just one example of the more than 250 recipes and over 100 full color photographs that you will find in EnLITEned Kosher Cooking: (With more than 140 kosher for Pesach recipes. It is the only kosher diet cookbook for Pesach.)

Gefilte Fish Recipe

EnLITEned Low-Carb Gefilte Fish
Carb Free, Low Fat. Yield: 12 servings

Don’t save this dish only for Shabbos or Yom Tov. This tastes just as good as the high-carb version and it’s almost “free” for any meal or snack.

For fish:

1 medium onion, peeled
1/2 small carrot, peeled
1 whole egg plus 2 egg whites
1 pound ground fish (carp, pike, whitefish, or a combination)
sugar substitute equal to 1/2 cup sugar, divided
salt and white pepper to taste
1-2 tablespoons cold water, added by drops
almonds, finely ground (optional)

For fish stock:

fish bones and head (this is what makes the stock gel)
sugar substitute equal to 1/4 cup sugar
2 leeks, trimmed and sliced in half lengthwise
1 green pepper, seeded
2 celery stalks
1/2 small carrot, peeled
2 quarts water
2-3 cloves garlic, peeled salt to taste

Place fish bones and head in a 6-quart pot. Cut green pepper, celery and carrot into large slices and add. Then add leeks, garlic and salt. Fill pot half full with water and bring to a boil.

To make the fish, put onion, carrot and eggs in a food processor or blender. Process until completely smooth. Add to ground fish, along with sugar substitute and seasonings.

Mix, preferably with an electric mixer. Add drops of cold water and continue beating for a few more minutes until the mixture holds together well. There is no need to add matzoh meal. If the mixture seems too loose, add finely ground almonds, 1 tablespoon at a time. Mix between additions, and stop once it holds together nicely. When using carp alone, you won’t need any almonds. When combining different fish, the consistency may be looser and then you may need to add 1-3 tablespoons.

With wet hands, form mixture into medium balls and drop into the boiling stock, making sure they are covered. Add water if necessary.

Cover pot, lower heat and cook for 1½ hours. Check every 15 minutes or so to make sure that there is at least 1-2 cups of liquid, adding water if necessary.

Cool. Remove fish and carrot with a slotted spoon and put in a container. Cover with the cooled liquid or place liquid in a separate container for garnish when serving. The fish stock will gel.

Serving suggestion:

Serve fish with a slice of carrot and horseradish.
Variation:
For non-sweet gefilte fish, eliminate the sugar substitute and add:
To stock:
2 more cloves garlic, peeled and halved
salt and pepper to taste
To fish:
1-2 cloves garlic, peeled and finely minced
salt and pepper to taste

Nutrition Facts
Serving size (ball) 1 (oz) 1.5 (g) 45
Calories 54
Protein (g) 7.5
Carbs (g) 0.8
Fat (g) 2.4
Sat. Fat (g) 0.6
Cholesterol (mg) 28
Sodium (mg) 75
Calcium (mg) 27
Fiber (g) 0
Exchanges: Lean protein 1

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1 . This assumes the whole matzoh (before it is broken) has a diameter of at least 10.25 inches, which means the entire matzoh has an area of 83 sq. in. Hence, 1/6 of the matzoh is 13.75 sq. in. This is the minimum shiur for someone with a medical condition.

2 . This assumes a full rectangular matzoh is 6 1/8“ x 7“, which means the entire matzoh has an area of 43 sq. in. Hence, 1/4 of the matzoh is 10.75 sq.in. (This also means that one could eat a piece of matzoh that is square, with each side being 3.3 in. in length and width.) This is the minimum shiur for someone with a medical condition.

3. This assumes the whole matzoh (before it was broken) had a diameter of 10.25 in., which means the entire matzoh has an area of 83 sq.in. Hence, l/3 of the matzoh is 27.5 sq.in.

4. This assumes a full rectangular matzoh is 6 1/8” x 7”, which means the entire matzoh has an area of 43 sq. in. Hence, 1/2 of the matzoh is 21.5 sq.in. (This means one could eat a piece of square matzoh that is four and two-thirds inches [4 .66 in.] on each side.)