March 2025

The challenges of diabetes and other health conditions are magnified on Pesach. Aside from the numerous large meals that we have on any Yom Tov, Pesach adds a new set of concerns: the consumption of four cups of wine and set amounts of matzah during the Seder. Before discussing the challenges specific to the Seder, let’s begin by addressing eating during Pesach generally.

Eating Well on Pesach: Tips and Strategies

Enjoying our Yom Tov meals is an important aspect of how we celebrate Pesach. A health concern that may impact how you eat need not decrease your enjoyment of Pesach. There are many aspects of meals on Pesach that can be optimized to enhance your enjoyment.

► Designing the Menu

• When planning your meals, consider the variety of foods. Having multiple foods on the table that are good for your health will allow your meals to feel plentiful. For some people, that means having only one carbohydrate side, with multiple vegetable or salad options.
• Consider your preparation methods. Choosing recipes that have unique and varied seasonings and spices will enhance the pleasure from those dishes.
• Think about the other sensory characteristics of the food you are preparing – vary the temperature, texture, color, size and shape of the food you serve for a more exciting meal experience.
• Remember that your meals do not need to mirror how other families eat on Yom Tov. If multiple appetizers lead to overeating, then changing that can help you eat better and feel better on Pesach. Because of this, some families skip the soup and fish courses and go straight to the main dish. Other families have chicken soup and fish with salad and skip the main dish for night meals.

When your health is your concern, think twice if you feel you need to prepare a meal that conforms with what “everybody else” is doing or what you experienced growing up. Feel free to create the menu that best suits your family’s needs.

► Setting the Mood

Consider the décor if that is a factor that makes a meal nicer for you. Get pretty napkins, buy flowers, and use pretty dishes if doing so will enhance your meal. For some, the lighting affects the ambiance, so use candles or softer lighting to give your meal a cozier feel.

► Having Good Company

Other factors that can make the meal more pleasurable are the social aspects. Invite family or other guests, if you enjoy that. Talk to your family members and guests during the meals. Some families plan discussion starters related to the chag or other acceptable topics to keep the environment pleasant. If your family likes to share divrei Torah, make sure they are age-appropriate for all children if you expect them to sit quietly. Otherwise, set realistic expectations for your children’s behavior to keep the environment calm and happy. Other families like to sing together, tell stories or get the children involved in the conversation.

Taking steps to prevent extra stress at meals will make your meals more pleasurable. Often, our unmet expectations can lead to stress and anxiety, so stay realistic. Allow yourself to prepare easier dishes if that will make your Yom Tov more manageable. Don’t expect your children to share divrei Torah or be patient beyond what is age-appropriate. Remember that the meal is primarily for yourself and your family and not to impress your guests.

When both the food and the environment of the meal are considered and optimized, you can have a delicious and comfortable meal that is satisfying, from both a gashmius and ruchniyus aspect.

Medical Conditions

► Diabetes

Two Sedarim will not “make or break” someone’s diabetes care. If someone’s blood sugar averages at normal levels throughout the year, and then over the first two days of Pesach it averages somewhat higher, that is unlikely to cause long-term diabetes complications.

Although it is important to care for one’s health every day, it is important to understand – in the context of a person’s normal life – what two days per year means. In contrast, if someone has very high blood sugar at baseline, the Seder is the least of their worries, as this person is at high risk of complications even if they use the smaller shiurim.

Besides using smaller shiurim at the Seder, there are other things one can do to improve blood sugar on Pesach. These choices are more impactful on blood sugar than using smaller shiurim.

• After the Seder, walk your guests home. This walk can help lower your blood sugar.
• Maintain physical activity throughout Yom Tov. Take a walk after your day meals. On Chol Hamoed, go on active family trips – visit the zoo, go on a hike, go canoeing/kayaking or visit a large museum.
• Additionally, choices of food at mealtimes throughout Yom Tov are more important than merely smaller shiurim at the Seder.

At the Seder: Type 1 vs Type 2 Diabetics

Type 1 Diabetics:

• In general, those with type 1 diabetes will not need to use smaller shiurim for the Four Cups or for matzah. They just need to know how much carbohydrates are in those foods so they can dose insulin appropriately.
• They will likely have to use grape juice rather than wine because they are using insulin. Using insulin makes it more likely that alcohol will cause low blood sugar.

Type 2 Diabetics:

• Those with type 2 diabetes may benefit from using smaller shiurim for matzah, and if they are unable to drink wine, then diluted shiurim of grape juice (see Section C below).
• For those who can drink wine, dry red wine is the best choice, as it is almost carbohydrate-free.
• Those who are taking insulin or sulfonylureas (e.g., glimepiride, glipizide or glyburide) may be advised by their healthcare provider to avoid alcohol due to the higher likelihood of low blood sugar while taking these medications and alcohol together.
• Consuming whole wheat matzah will somewhat decrease the amount of digestible carbohydrates. This can be a factor in leading those with type 2 diabetes to prefer whole wheat matzah.

Using Diabetes Technology

Diabetes technology is used to improve diabetes care and outcomes. Some types of diabetes technology include glucometers, continuous glucose monitors (CGMs,) and insulin pumps.

• Glucometers involve a fingerstick for blood and placing the blood on a test strip in a little machine that will provide a reading of blood sugar at that moment.
• CGMs use a small filament under the skin that checks blood sugar every few minutes without a fingerstick for blood. The results are sent to a receiver or the person’s cellphone.
• Insulin pumps are small devices that provide insulin to the person throughout the day and larger doses at eating occasions to maintain blood sugar in the goal range.

Using a device to check blood sugar, whether a glucometer or CGM, allows the person to make care decisions based on their blood sugar reading in the moment. For example, one who uses insulin and whose blood sugar is trending low may choose to eat something that contains carbohydrates or decrease insulin provision. Alternately, those with type 2 diabetes who note their blood sugars are high at the Seder may realize that smaller shiurim are necessary for them.

In general, those who use any of these devices daily to manage their diabetes are permitted to use them on Shabbos and Yom Tov. According to Rav Moshe Heinemann shlit”a, if the glucose testing draws blood, on Shabbos and Yom Tov – if practical – it is preferable to do so with a shinui.

Those who do not currently use diabetes technology but who would benefit from doing so should use it daily, without interruption. Check with your healthcare provider if your health can benefit from using diabetes technology. Regarding the use of this technology during the Seder and on Yom Tov, in general, the earlier you start using it, the better. Consult with your rav regarding all technology usage on Shabbos and Yom Tov.

► Alcohol Use Disorder

One with Alcohol Use Disorder who is practicing abstinence should not drink any alcoholic beverages, including wine, at the Seder or at any other time on Pesach. These individuals should drink grape juice instead. One who regularly drinks larger amounts of alcohol should not suddenly stop because doing so can lead to withdrawal. The best time to work on reducing alcohol intake or detox is well before Yom Tov, and under medical supervision.

► Eating Disorders

The category of eating disorders encompasses a wide variety of disordered eating behaviors. In general, treating eating disorders is benefitted by increasing variety of foods and decreasing food restrictions.

One should discuss with their rabbi regarding eating egg matzah and kitniyos on Pesach if there is a potential therapeutic benefit.

Additionally, all food chumros the person follows on Pesach and throughout the year must be discussed with a rav.

Individuals with eating disorders may have comorbid gastrointestinal diseases or symptoms, and sometimes those conditions are benefited by eating foods that can be easier to digest, such as egg matzah rather than regular matzah. Although egg matzah can not be used to fulfill the obligations to eat matzah during the Seder, there may be a therapeutic benefit of eating egg matzah during other occasions on Pesach. Consult with your rav.

► Constipation

Constipation can range from easy to manage to quite serious in some individuals. Those at risk for constipation include those on some psychiatric medications, GLP-1s, elderly individuals, pregnant women and people with limited mobility. Constipation can be managed a variety of ways, and for many people with constipation, with a bowel regimen: a few medications and/or supplements that are used in combination. Most of these are acceptable on Pesach. Check Rav Gershon Bess’ Medicine List in the STAR-K Pesach Guide for approved items.

Matzah is known to worsen constipation. For some individuals, this can be remedied by drinking plenty water throughout the Seder and throughout Pesach. Maintaining physical activity, even a short 10-minute walk after the Seder and meals can help with constipation. Those who do not use medication for constipation year-round may need to on Pesach.[1] If you have experienced constipation in past years, familiarize yourself with available medications and products that can be used on Pesach. Some individuals may need to use the smaller shiur of matzah due to constipation.

Remember that whole wheat matzah is higher in fiber than regular matzah. For those who regularly consume a low-fiber diet, suddenly increasing fiber intake can lead to constipation. Fiber intake should be slowly increased over a few weeks. If you rarely eat high fiber foods, it is advisable to choose regular matzah rather than whole wheat matzah.

► Celiac Disease

Those with celiac disease must not eat any gluten. Eating gluten with celiac disease can cause gastrointestinal pain in the short term, nutrient deficiencies in the medium term, and increased risk of rare intestinal cancers in the long term. Oat matzah may be used by those with celiac disease to fulfil the mitzvah of matzah at the Seder.

Kosher for Passover foods labeled “non-gebrokst” do not contain matzah meal[2] and are gluten-free, a plus for those with celiac disease. Often, those with celiac disease stock up on non-gebrokst Kosher for Passover baked goods to use year-round as gluten-free options. 

See also “Advice for People With Celiac, Food Allergies and Gluten-Free Restrictions on Pesach” on the STAR-K website for more guidance for individuals with celiac.

Preparing for Pesach with a Medical Condition

The key to a successful Pesach with a medical condition is preparation. See your healthcare providers regularly throughout the year and take your medication as prescribed. This can allow you to enter Pesach optimized and in good health. You will have already discussed with your healthcare provider what Pesach requires of you, and it won’t be a last-minute scramble to get in touch with your provider. It is always best to talk to the provider who knows you best, not whoever you can get in touch with last minute because you forgot to address your Pesach-related health concerns earlier.

Halacha tells us how much wine and matzah one must eat at the Seder. Anyone whose healthcare providers recommend dietary modifications that affect eating matzah or wine should consult with a rav to find out how to follow those health recommendations within halachic guidelines.

Shiurim for Matzah

The guidelines for minimum shiurim for matzah shown below are based on the psak of Rav Heineman. For hand matzah, these calculations are based on Pupa-Tzelem matzos, which are approximately 9 matzos/lb. (Note that matzos baked by other matzah bakeries may be of different sizes/weights, which naturally will affect the amount required for a shiur as well as the carbohydrate content of that shiur.)

Those in good health should eat the following for Achilas Matza[3] and Afikomen :

Type	Minimum Shiur	Dimensions	Carbs (g)
Hand Matzah (round)	one half (1/2) of a matzah	43.3 sq. in.[4]	22
Machine Matzah	one half (1/2) of a matzah	24.5 sq. in.[5]	11.5-16

In the case of a medical condition (e.g., diabetes) which could be negatively impacted by matzah consumption, one may fulfill the mitzvah of Achilas Matzah, Koreich and Afikomen with the following:[6]

Type	Minimum Shiur	Dimensions	Carbs (g)
Hand Matzah (round)	One-quarter (1/4) of a matzah	217 sq. in.[7]	11
Machine Matzah	One-quarter (1/4) of a matzah	12.25 sq. in.[8]	6-8

If you need to know the carbohydrate amount for machine matzos, use the carbohydrate data on the nutrition facts label for a more accurate value.

Shiurim for the Arba Kosos (Four Cups)

(A) Wine

Cup requirements: The cup you use for the Four Cups must hold at least a revi’is (3.8 oz. or 112 mL).

Minimum shiur to drink for the Four Cups: One must drink at least 1.9 oz. (56 mL) for each of the Four Cups.[9]

Additional Requirements:

• The basic requirement is to drink wine with at least 4% alcohol.
• When drinking each cup, complete the shiur within 30 seconds.

(B) Adjusting for Medical Concerns

If someone needs to minimize carbohydrate intake (for example, they have Type 2 diabetes), the best choice of wine is a dry red wine. These have 1g (or less) of carbohydrates per ounce of wine. At the regular shiur, if one drinks the minimum of 1.9 oz., they will only consume about 2 g of carbohydrates per cup. If one with type 2 diabetes is not able to drink alcohol, the best option is diluted grape juice.

If one is taking medications that should not be taken with alcohol, they must avoid wine at the Seder and drink grape juice instead. Do not stop any medication in order to drink wine at the Seder without consulting your healthcare provider. Those with alcohol use disorder who are abstinent from alcohol must not drink wine at the Seder. In all cases, consult your rav for guidance.

(C) Diluting Wine with Grape Juice and Water

            Higher carbohydrate wine may be diluted in the maximum ratios listed below. These ratios allow the wine to retain enough of its properties to qualify it being used for the Four Cups:

• 1/3 wine and 2/3 grape juice
• 1/3 wine, 1/3 grape juice, 1/3 water
• 1/3 wine and 2/3 water (see below)

            The diluted wine must contain at least 4% alcohol.[10] If there is a health issue, it is advisable to start with wine that has at least 12% alcohol, then dilute it to 4% alcohol by adding up to 2 parts water to 1 part wine (i.e., a ratio of 2:1).[11] When diluting to have 1/3 wine in your cup, you will consume slightly more than 0.6 oz. wine per kos. This is about 2.6 oz. for all four cups. This is assuming you drink 1.9 oz. from a 3.8 oz. cup. When using dry red wine, this is less than 1g of  carbohydrates per kos.

(D) Grape Juice and Diluted Grape Juice

Although drinking wine is preferable for someone with no medical concerns, when it is necessary for medical reasons, a person should drink grape juice. The minimum shiur (1.9 oz. from a 3.8.oz. cup) of regular Kedem grape juice has about 9g of carbohydrates. If pure grape juice is not acceptable due to medical needs, diluted grape juice should be used. Light Grape Juice may not be further diluted. The minimum shiur (1.9 oz. from a 3.8 oz. cup) of Light Kedem Grape Juice has about 6g of carbohydrates.

One can also prepare their own diluted regular grape juice by following the proportions below:

GRAPE JUICE	WATER
51% or more (i.e., more than half)	49% or less (i.e., less than a half)

Ideally, this mixture should be prepared before Yom Tov to allow for the most diluted concentration of grape juice that can be used for the Four Cups. In a dedicated container, prepare 16 oz. of grape juice and 15 oz. of water. This mixture will provide enough grape juice for the Four Cups for both Seder nights, assuming your Seder cups are the minimum 3.8 oz. size. Drinking the minimum shiur (1.9 oz.) of this mixture equals about 4.5g of carbohydrates.

(E) Egg Matzah

Matzah made with more than just flour and water is known as “egg matzah.” Egg matzos can include eggs, fruit juice, honey, seasonings, among other ingredients. According to Ashkenazic practice, they may not be eaten on Pesach except by those who are sick or elderly. These include “Kosher for Passover” Egg Matzah Crackers and Egg Matzah Tams.

Although it is permissible for those who are ill or elderly to eat these products on Pesach, they may not be used to fulfill the obligation to eat matzah at the Seder. Medical conditions that may necessitate eating egg matza on Pesach are gastrointestinal conditions and eating disorders. Unless there are other complicating factors, people with diabetes would not benefit from eating egg matzah instead of regular matza. Consult with your rav.

(F) Sugar Substitutes

Powdered Equal, Splenda, and NutraSweet sold year-round are NOT Kosher for Passover, and may not be used on Pesach. For a list of Kosher for Passover sugar substitutes available in stores, see the STAR-K Product Guide.

An abridged version of this article is available, along with a downloadable PDF summarizing all the shiurim noted above.

STAR-K thanks Mrs. Brendel Plonka, MS, RDN, CDCES, CNSC for her invaluable assistance with this article. Brendel provides medical nutrition therapy for adults and children in her private practice. She can be reached at brendelplonkardn.com

---

[1] This is always permissible on the second and last day of Pesach. However, on Shabbos or the first day of Yom Tov (i.e., the first or seventh day of Pesach), only one who is a choleh may take medicine. One experiencing a meichush (discomfort) may not take medicine. Consult your rav to determine whether your constipation is enough to warrant medicine on Shabbos or the first day of Yom Tov.

[2] Items containing matzah meal are gebrokst and not gluten-free.

[3] For Koreich, see Rabbi Mordechai Frankel’s article, “Halachos of the Pesach Seder,” in the Koreich section on page.

[4] This assumes the whole hand matzah (before it was broken) had a diameter of 10.5 in., which means the entire matzah has an area of 86.6 sq. in., hence, 1/2 of the matzah is 43.3 sq. in.

[5] This assumes a full rectangular machine matzah is 7” x 7”, which means the entire matzah has an area of 49 sq. in. Hence, 1/2 of the matzah is 24.5 sq. in. (This means one could eat a piece of square matzah that is 5 in. on each side.)

[6] This means for each mitzvah one eats the designated amount within a 4 minutes span. For example, in case of a medical condition one may eat 1/4 of a machine matzah within a four-minute span to fulfill the mitzvah of achilas matzah. The same amount within the same span of time should be done for Koreich (with a kezayis of maror) and then for Afikomen.

[7] This assumes the whole hand matzah (before it is broken) has a diameter of at least 10.5 inches, which means the entire matzah has an area of 86.6 sq. in. Hence, 1/4 of the matzah equals 21.7 sq. in. This is the minimum shiur for someone with a medical condition. If someone requires shiurim even smaller than this, or is unable to eat matzah, Koreich and Afikomen, he should consult his rav. For a discussion of such shiurim, see Rabbi Mordechai Frankel’s article “Halachos of the Pesach Seder” at star-k.org/passover.

[8] This assumes a full rectangular machine matzah is 7 in. x7 in., which means the entire matzah has an area of 49 sq. in., hence, 1/4 of the matzah equals 12.25 sq. in. (This also means that one could eat a piece of matzah that is square, each side with a length and width of 3.5 in.) This is the minimum shiur for someone with a medical condition.

[9] This is the minimum shiur. Regarding how much of the cup one must drink l’chatchila, see Rabbi Frankel’s article, “The Halachos of the Pesach Seder,” in the Four Cups section.  

[10] This is to fulfill the obligation of wine. If one cannot drink wine, he can fulfill his obligation with grape juice. This is discussed further below, in Section D.

[11] If the alcohol content is 9%, then dilute it with less than 55% water.