Powering Through Passover with Type 1 Diabetes: Episode 29

Welcome to Think Like a Pancreas, the podcast where our goal is to keep you informed, inspired, and a little entertained on all things diabetes. The information contained in this program is based on the experience and opinions of the Integrated Diabetes Services clinical team. Please discuss any changes to your treatment plan with your personal healthcare provider before implementing. So welcome everybody to today's podcast. I'm Gary Scheer, and I am thrilled to be joined by my friend

and colleague, rabbi Hirsch. Meisels. I. Rabbi, tell us a little bit about yourself. Yeah, thank you, Gary. We've seen each other many times and thanks for getting me on this show. So Shalom. My name is Rabbi Hirsch Mazel. I've been living with Type one diabetes for the past 46 years. Currently I use a tandem basal IQ insulin pump, alongside with a Dexcom G six sensor to help manage my diabetes.

I'm the founder of Friends with Diabetes, an organization established 30 years ago with the mission of helping individuals integrate Jewish lifestyle while managing Type one diabetes. Our goal is to provide guidance on how Jewish law called HALAKHA relates to managing diabetes and offer social and emotional support to those living with the condition and their families. We run support groups with children.

Teens, parents and adults helping them navigate life with diabetes while maintaining a strong connection to their faith and community. I've had the pleasure of participating in almost a dozen of your programs over the years. Um, I, I find them soulful. I find them rejuvenative. The tremendous learning opportunity. I always make new friends, so the name Friends with diabetes is a very appropriate one. Uh, those are tremendous programs for the Jewish community.

And like you, I I've been through my share of Passovers with diabetes. I'm coming up on 40 years. I haven't quite caught you, but I'm still, I'm still trying catch up on 40 years with type one and, uh, 40 years of Passovers. Uh. Through the mix. So our, our, the title of our program today is Powering through Passover. But it's interesting, a lot of people find Passover challenging

when you have diabetes. I find that my glucose control improves for the eight days. Uh, I find I'm more on track with my diet because. Stuff I normally nos on. I'm not notching on, uh, the restaurants I might normally go to. I'm not going to, I, I do a better job with my, my eating during those eight days, and hence I've got better glucose control. During that time, what have you found to be the case for you? Is your blood sugar better or worse, or about the same? During Passover?

Sometimes on the first few days I'll struggle with some low blood sugars. Until I got used to this new regimen. But yes, you're correct. Uh, with less food choices around blood sugar control is much easier. So, uh, yeah, the, the lows, there's a lot to work out those first couple of days. You know, there's a lot of details and response, new responsibilities and that mental energy can, can contribute to a bit of a glucose decline. So for our non-Jewish listeners, and we have quite a few.

Can you tell us, uh, just the quick summary of what Passover is all about? Let's try. Passover or Pesach is one of the most significant holidays in the Jewish calendar celebrating the liberation of the Jewish people from slavery in ancient Egypt, the holidays spent eight days with the first two nights centered around the Seder. Special meal that includes symbolic foods, prayers and storytelling.

The Seder is an opportunity for families to retell the story of the Exodus, using the hagada to guide them. The children traditionally ask the four questions which help engage everyone in understanding the holidays, meaning the symbolic foods on the CER plate include matza and unleavened Bread represents the bread the Jewish people ate in their Egypt. Bitter herbs, usually horseradish symbolizes the bitterness of slavery and wine.

Four cups are drunk during the Seder to symbolize freedom and redemption During Passover, Jewish people refrain from eating chametz, levan foods like bread and pasta for eight days, and remembrance of the unleavened bread they ate during the exodus. Some individuals, particularly among Ashkenazi Jews also avoid legumes. Called kitniyot during this time, these dietary restrictions can make, can make finding suitable, ready-made foods challenging.

So it's important to choose products there are specifically certified as kosher for Passover. Do you have any, uh, traditions outside of the normal, you know, reading of the Haga? I know we, we, uh, we hide the Afikomen. The afikomen is a--that half piece of matza that you wrap and, uh, someone in the family hides it and one of the children is supposed to find it and they get a, you know, a prize if they're able to. Uh, so we always have fun with that.

But we, we send the adults scouring the house as well. We, we find some creative places to hide the afikomen, so that, that's kind of a fun activity. You do anything like that at your Seder? Yes. It's part of the Seder ritual. Uh, by us. We don't really hide it On the couch, we sit on, there are two pillows and we just put them between the two pillows.

The, the kids try to take it away when father is not seeing, and then when the time comes to eat it, which is the last food eaten during the night, the father looked for the a Tacoma, can't find it, and asked who stole the ama, and then they would come back. And try to argue, if you promise me to do this or get me this, I'll give it back to you. That's sort of permitted stealing.

Yeah. Our other family tradition is, uh, one of the, you know, post meal songs, Chad gadya, we all take on the role of one of the characters. Uh, and my mother-in-law, God rest her soul, she used to be the ox and she would make the sound of an ox that. Would frighten the, uh, you know, frighten anybody who could hear it. Uh, and we would all come up with these creative voices to animate the, uh, different characters in the song.

So it was always a fun, fun ritual that our family, uh, likes to do. So the, the Seders usually take place the first two nights of Passover.

Um, and there's a lot about the Seder that's different from a, a normal evening meal. What do you find are some of the bigger differences between a Passover Seder and a normal meal starts much later at night, way, way after sundown, and it ends usually not before midnight or many hours later. Very different schedule.

And then having to say to recite all the hagada and many families with many translations and commentaries and stories, this takes a long time, even before we start, the actual meal could take between one to two hours until we get to the actual meal, which would be very late at night. So for somebody with diabetes who takes insulin specifically. That can create some challenges.

People who are on injections, uh, might start to see their glucose decline while they're waiting to eat late into the evening. And even, you know, just that long drawn out aspect of the meal can, can be problematic. Somebody who takes injections might find that their insulin is working before they have a chance to finish their meal and could go low from that. Uh, insulin pumps offer us some opportunities to manage a little bit better.

How do you use your insulin pump to manage your glucose with that kind of a meal? Interestingly enough, as you mentioned, the The Seder is different for every family. We always eat it with family. We have no clue how other families do it. Like you mentioned with the  Chad gadya, I've never heard this, so by us. Interestingly enough, we have to finish the last piece of matzah for the  Afikomen, and then we can't eat anything, anything afterwards.

We have to finish that before midnight and think about starting the whole Seder when it's already dark or later. The Hagada would take one to two hours. There's not much time left for the actual meal. Traditionally, in our family, it's a extremely rushed meal. Shorter than a typical holiday or Shabbat. I never had that problem with prolonged eating in terms of the insulin.

But if people do it the other way around and the meal is a dragged out meal, they'll have to handle this like with any other holiday extended meal. And each person's different. Many families, uh, the story of of, of the Passover run through the the  Hagada, and then the meal actually goes on for several hours. Uh, you know, there's a lot of courses, et cetera. There might be some prayers set during the meal, some songs that are done during the meal and after.

We used to save the dessert items until, uh, after all the post dinner songs, uh, and prayers take place. So the meal part can sometimes go on for quite a while. And, uh, the pumps give us a chance to, you know, dose our insulin as we go fairly easily. And there's a feature in most pumps called an extended bolus that can be used as well.

The interesting thing about some of the newer systems that are out there, like the Tandem, the the Omnipod five and the Medtronic, and even the open source systems is some of them don't allow you to extend boluses while they're making automated adjustments. So you have to turn off the automated feature to extend the boluses for those drawn out meals, but I find it's still worth doing. Uh, you know, the one food that is most closely associated with Passover, of course, is matza.

Tell everybody what matza is. Matza is basically flour and water, nothing else. Pure starts, high glycemic index. If it's not whole wheat, if it's whole wheat, it's a bit better or spelt. And, uh, eating mat could potentially raise blood sugars to very high level and very rapidly, very quickly, high speed. Um, many families have a custom not to mix the matza with anything else. No spreads on it, no dips. So this takes away the advantage of having it mixed with a protein or a fat.

So it stays a high glycemic index and, and, and it is an issue. Yeah. So if somebody is taking their, a bolus of insulin for matza, uh, they need to ideally take in it adv in advance. Because that matza does raise the glucose very quickly, but you mentioned toppings and dips. Uh, chopped liver, for example, would certainly slow down the digestion of the matza a bit to keep it from spiking the glucose all at one time. Uh, so that's an option people can turn to.

Um. Other than Matza, well let, let's talk about the matza a little bit more. Now. The carb counting, uh, can be a little bit of a challenge, but you've come up with some techniques and tools that can help people estimate the carbs in Matza, as well as some other peoc foods. Any, any tricks you can share about Matza carb counting? People using machine matzah, the square matzah, they're pretty simple. They're usually not too heavy.

Would be about one ounce each, and you'll get somewhere between 20 and 25 carbs per matzah board. It's not overdone if you eat one whole matzah. That's usually simple. When it comes to the matzah, we use the Ultra Orthodox, the round Shmura matzah, they can be very heavy, large. And discrepancies between one matzah and the other matzah in the same box. So there's no real choice but to weigh on a scale the portion you are consuming.

What I've come up with is that matza, roughly I like averages, makes life simpler. It's roughly 70% carbohydrates. The other 30% I guess, is the water or whatever else is in the wheat. 70% is carbohydrates. The way the, the easy way would be put it on a scale, use a calculator to calculate the carb counts, or, in my mind, I have a simple way of doing it. I view it as 10 gram portion. Each 10 gram portion would be seven carbs, 70% of 10.

Seven. If I would eat a whole matza, which would be 60 grams, then weight, I'll view it in my mind as six such portions, each portion having seven carbs, six times seven, and you got the answer 42. Roughly. If you matza weigh 70, 70 of such portions, seven times seven would be 49. Sure. That's easily done in my brain. If someone doesn't, you know, have a a food scale. I teach them how to use surface area. This the volume, this, the kind of the radius, the di, or the diameter of the matza.

As a way to estimate, if someone had a round matza that was the size of a hand with the fingers spread, about how much carb would you estimate that to be? I would say it's, it weighs 20. Then it's, you got 14 grams, 14 carbs. Okay. The problem, the challenge with the matzah we use, which people make by hand is that the thickness of each mat could be different. Mm-hmm. It's, it's, the real best way would be, uh, using a scale in particular.

It's so high in starches, it's so high in carbs, and so rapid glycemic index, we wanna try to be as accurate as possible. Okay. We teach, uh, I, I use pizza as an analogy with the matzo. Yeah, you're right. If you're getting pizza, you could have thin crust, hand tossed, deep dish. It, it varies a lot. So we, we teach with pizza. A hand size piece is about 30 if it's an average thickness of crust, if it's thinner, it's 20.

If it's thicker, it's 40. So as a general rule of thumb around matza, the size of a hand is gonna average about 15. If it's a thicker. Type of a matza might be 20. If it's a thinner, it might be 10. So if somebody just has to ballpark it, they don't have a scale available that that's one way they can do it. The scale will give you the more accurate measure, but you could estimate pretty closely, at least if you use that 10, 15, 20 number for a hand size piece of matza.

Of course, we're talking about an average adult man's hand. You know, a, a woman or a child is gonna have a smaller hand, you got a different number. So you, you gotta have a man's hand on, you know, handy to be able to do that properly. So with Matza, getting the carbs right or close is part of the challenge. The other is the timing. And as you said, it's a very high glycemic index food. It's gonna raise the glucose very quickly.

So pre bolusing taking insulin, 10, 15, even 20 minutes ahead is ideal. Most other foods we eat on Pesach, most of the starches are potato based, so we're not having, you know, many other types of starches other than potato and potato. At least white potato is also a very high glycemic index food. So we're looking at a lot of high GI foods. So pre bolusing on Passover throughout the week is gonna be necessary to avoid the big spikes and drops throughout the day. That is that safe to say?

Definitely safe to say. People will try to limit their starches like low carb dieters, et cetera, could do the same thing on Passover. We eat meat, chicken, fish. Many families do eat dairy, some don't. There's still enough protein options. Whichever way you use potatoes during the, during the year, you could do the same on Pesach, add some fat, eat it together with protein, don't overeat. You know, all the tips you use around the year could be used on Pesach as well.

I've discovered the joy of matzo with cream cheese. I find that very tasty, and if I slather on a decent amount of cream cheese, it does slow down the digestion, uh, a decent amount. You know, I'm not encouraging everybody to load up on a ton of fat during Passover, but you know, like you said, chopped liver dips, things like that, it can help a bit. A word from our sponsor.

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Um, wine is another important aspect of the Passover Seder drinking multiple glasses of wine. Or, you know, the young people might drink grape juice, but let's talk about wine first. 'cause wine can have more than one type of effect on glucose levels. It can raise it. It can lower it. Can you talk about that a little bit? It's always the question to choose between wine or grape juice. For the four cups during the Seder, it's always important to be mindful of blood sugar levels.

Grape juice on one hand are high in carbohydrates and cause rapid spikes in blood sugars, especially when consumed in large quantity. For those managing diabetes, I often recommend to dilute the grape juice, dilute the grape juice with water, or opt for a lower carb option like cas light grape juice. Wine, on the other hand, can have a different effect, and as you mentioned, could have, it's a double whammy as it's double-edged sword alcohol.

Can lower blood sugars by inhibiting livered release of glucose, especially when consumed before a meal on an empty stomach. For people with diabetes, it's crucial to manage this carefully or in large quantities Or in large quantities. Um, sweet wines are also going to have the opposite effect, that you could have a rise in blood sugar levels and following a dip. I'll get into a low blood sugar. Dry wines typically have fewer carbs or none, but much more alcohol.

Moderate wines like Chablis provide a better balance, not too much alcohol and not too many carbs. That would be a good, uh, in between. Yeah, I find with the, uh, the dry wines, you know, higher quality wines, uh, we don't tend to see much of a glucose rise. There might be one or two grams of carbohydrate or sugar per glass, but the alcohol can accumulate.

Somebody who has four glasses of wine has a decent amount of alcohol there, and if the liver isn't making as much glucose as usual after the Seder, blood sugars can drop overnight. People who use automated insulin delivery systems are somewhat protected against the lows, but if you wanna play it safe. You can turn off the automation and then lower the basal insulin that you get during the night.

Uh, you would run a temp basal and maybe lower the basal by 30 or 40% through the night just to re lower The risk of of having a hypo and people on injections could cut back a little bit on the dose of long-acting insulin, whether it's Tresiba, Toujeo, Lantus, glargine, whatever they're using. Basaglar, taking that dose down a little bit just to protect against the low during the night.

The sweet wines though, uh, will usually it's like drinking grape juice with alcohol, essentially, they can cause a pretty rapid rise in the glucose. So I, I still recommend taking a bolus of insulin, of rapid acting insulin to cover the carbs in those, uh, four ounces of, of sweet wine or grape juice can have as much as 15 grams of rapid acting sugar in it, so it's necessary to dose for those. Go ahead.

Here's the recommendation I make-- prepare for the Seder, both options, a dry wine and grape juice. The first cup, which starts the whole Seder. You still have. Probably close to two hours until you're going to eat the meal without long period of time. I say you have to judge before drinking the first cup if, if you, if you should use grape juice or wine, if your blood sugar would be low at the start of the Seder, use grape juice for the first cup so it'll help you raise your blood sugars.

On the other hand, if your blood sugar is higher using a dry wine. It may actually help lower it, possibly without the need of a correction dose. It's interesting it, that's the same approach I use when I do any distance running. I'll get to a rest stop and I'll choose between water or a sports drink, depending on what my blood sugar is doing. So it's diabetes. We gotta make decisions on the fly a lot of the time, based on the situation, the sitting is another issue.

When we sit for long periods of time, our bodies are burning less glucose. We become a little less sensitive to our insulin and blood sugars can climb. So during a prolonged Seder, there may be a tendency for the glucose to climb throughout. Do you just not worry about that and let it happen? Or do you wanna address it and. Keep it from happening. Here's the way I address it. You know, the Hagada is like a long prayer.

Many pieces in it could be made into a song and just stand up and start dancing with the whole family. You do that once or twice in the middle of the Hagada. You're not sitting that long. You're actually moving a little. Get your body active. That helps with, uh, that issue of losing the insulin sensitivity. I love that approach. We should do that when we're on airplanes too. Sit in all those hours, just get up in the aisle and start dancing every hour. That works for me.

Um. Now, obviously in the Jewish faith, we have people who are orthodox, conservative, reform, reconstructionists, so there's, there's different levels of observance that take place. Is there anything about having diabetes, that should keep somebody from following

any of the observances during Pesach. Good question. Uh, as a general rule, Jewish law prioritizes health and wellbeing, allowing commandments or customs to be adjusted in life-threatening situations. However, adjustments can also be made for medical or health reasons, not just life-threatening circumstances. With that in mind, let's focus on, on on relevant details. Jewish law is complex and often there are different opinions on the same issue. Interpretations, yeah. Correct.

This is where a competent rabbi who understands the medical situation comes into play, helping to determine which more lenient opinion one should follow. For example, in Halakha Jewish law, there are various opinions regarding the amount of wine or grape juice required for each of the four cups during the Seder. Most lenient opinions suggests that only one and a half ounces. Per cup is necessary.

While other opinions may require up to five plus ounces per cup for someone with diabetes, drinking 20 plus ounces of wine or juice. If you wanna follow the most stringent opinion that could lead to significant blood sugar fluctuations. Therefore, it's important to follow the lean opinion and aim for a smaller amount. This would allow you to fulfill the Seder's obligation while effectively managing your health. Same would be true for matza as we discussed.

It's a pure star, a high glycemic index, it Ali to blood sugar spikes. Different opinions exist regarding the required amount of matza. Generally, it's recommended to eat around 30 grams at the beginning of the meal with additional portions as the meal progresses. If that amount would lead to erratic bot sugars, you can reduce and consult with a rabbi for guidance and how to adjust based on personal health needs. I'll give one more example.

Some families follow strict customs during Passover permitting only homemade products with everything prepared from scratch at home. However, there are situations such as managing diabetes where exceptions are made.

For example, using store-bought candy to treat low blood sugars during payoff is, is necessary and practical exception, allowing the individuals to maintain their health while still honoring tradition. That was actually the next thing I was gonna ask you was about hypoglycemia. Uh, what are some of the recommended products, uh, for treating hypos during pesach?

Technically we have kosher for Passover items, you know, all over the grocery store, and there are candies and all kinds of junk, uh, that, that we can get. Um, the typical. winkie or fizzers, they are not available and not kosher for Passover. Yeah, there's it called Smarties in the secular Yeah. Uh, interestingly enough that we, friends with diabetes recommend people if they use year round only one specific thing for lows, like in the case of Winkys, just use it for Passover as well.

Don't fiddle around. Okay. I'll use chewing gums for Pesach. It would take much longer time to raise your blood sugars. Just do the same thing you've done all year round. Grape juice is always an option as well. At home during case when we're at home, it's easy to have grape juice. When we're outside, we're going for a ride.

It's a little difficult to carry along the back drink or bottle of grape juice, so we look for some packet items like the candies to, to have them handy while going on a hike, et cetera. It's a shame Manchez doesn't make juice boxes. That would be so convenient. Yeah, the part juice boxes stick the straw in. Imagine taking a hike, there's enough you have to schlep along with you can fit better in the pocket. Yes, absolutely.

So considering, you know, Pesach is a fairly long holiday, eight days, there are a lot of, uh, dietary restrictions involved.

How important is it to manage blood sugar levels? During Pesach and there's a certain trade off with anything, should we just say, you know what, I'm just not gonna worry about it. Let the blood sugars do what they may. Or should we really still focus in and dig in and manage the glucose well like we normally do? What do you think? We've gotta live life. And quality of life is very important.

Uh, that's why we're here, to give them the easy tips on how to manage it easily so you don't have to go out of your way that much to still control your blood sugars. Whatever's doable is doable. If it's not, it's not. As you mentioned, happens to be that we have better blood sugar control during Pesach for whatever reason. I speculate maybe there are chemicals and the food all year round. Create a stress on the body. I don't know.

But yes, we do have an easier time controlling blood sugars, but uh, if one finds that it's impossible, you know, don't lose sleep over it. You try your best. Two nights are tricky. No. And the rest, just follow, follow the regular diet and try your best. And as we discussed, the most important would probably be the matzah and the potatoes. Once you know how to handle those, you're in good shape. It's refreshing to hear you say that.

Uh, I, I often have to remind my patients that the reason we manage our diabetes is to have good quality life. If we have to start sacrificing the things that give us a quality life to manage the diabetes, we're missing the point. We gotta live life first. We gotta enjoy ourselves and do our best to manage it, but don't let it interfere with what's really important. Family, friends, religion, the things that are, you know, really make, make life worth living.

Uh. If somebody's interested in learning more about friends with diabetes, how can they do that? Probably best would be to send me an email to be added to our email list. I think that's gonna be fairly easy. Uh, you can go onto my website. It's very outdated, but there you'll find an email to be able to communicate. To connect. The website is friends with diabetes.org. That's simple enough. Do you have any, uh, conferences coming up? Um, not in the near future. Thanks.

I know you, you've, you've had, you know, countless programs over the years, you know, mostly in the northeast, in the Greater New York area, but in other places as well. Some are for couples, some are for children, some are for adults, some are for men, some for women. Uh, and they're, they're just such, they're, it's a warm environment. People there have a lot of commonality and they do make, you do make a lot of friends there and you learn some valuable things and.

All within the context of a, a Shabbas weekend. It's terrific events and you have some excellent resources as well. Specific things about the various holidays and managing diabetes. Um, so just to summarize, a, you know, Passover is, uh, it's an eight day holiday. It's commemorating the exodus from Egypt by the Jewish people to observe and recognize the holiday. There are certain dietary restrictions that are placed, number of ritual meals. That occur.

And they include some challenging things like matza. Uh, there's a lot of potato products because we don't have, you know, bread or anything that, that contains yeast or can rise. Uh, wine is a big part of, of the holiday. Um, and, you know, there are tricks for, for managing diabetes effectively. Talked about, you know, estimating the carbs in Matza as well as specific carb counting techniques, adjustments for alcohol.

Um. Adjustments for changes in activity level or making sure you still get some activity even during, uh, prolonged ritual meals. And, uh, point, I think we missed point. Point is enjoy it. Enjoy pay. That's what it's, it's meant for, uh. If your diabetes isn't just so, that's okay. We do our best. That's all. Anyone can ask for. Anything important that I missed? I think we missed one point regarding the Seder.

I only say it because I've heard people, newbies, especially, uh, doing it, doing it the wrong way. From when we start the Seder night until we get to the meal, could take a long time. Taking your insulin before the Seder begins would be a very bad choice. I mean, you would pass low even before the meal, um, to, to, to think about the insulin. The appropriate time would be right before drinking the second cup, which is followed by the meal.

So there, and then before drinking the second cup, you can factor the insulin for the second cup. The mat, the meal, and even the third cup, they could all, all could be included in, in that one bolus, regular or extended right before the second cup. Thank you for sharing that. Uh, I often tell my patients that getting the right amount of insulin is only half the battle. The timing has gotta be right. So thank you for sharing that.

And Rabbi, thank you for taking time outta your busy schedule, um, to join me today on the Think Like a Pancreas podcast. Thanks for tuning in to Think Like a Pancreas, the podcast. If you enjoy today's episode, don't forget to like, follow, or subscribe on your favorite podcast app. Think like a pancreas. The podcast is brought to you by Integrated Diabetes Services where experience meets expertise, passion meets compassion, and diabetes care is personal because we live it too.

Our team of clinicians all living with type one diabetes understands the challenges firsthand. We're here to help no matter where you are in the world. From glucose management to self-care strategies, the latest tech, sports, and exercise. Weight loss type one. Pregnancy and emotional wellbeing. We've got you covered. We offer consultations in English and Spanish via phone, video, chat, email and text. Wanna learn more?

Visit integrated diabetes.com or email info@integrateddiabetes.com to schedule a consultation. On behalf of Think Like a Pancreas, the podcast. I'm Gary Shiner, wishing you a fantastic week ahead, and don't forget to think like a pancreas.