,uthrc vfkvf hfjk eu,n A NOTE FROM Rabbi Y. P. Bodner shlita AUTHOR OF HALACHOS OF KZAYIS UIDE sWxc cWxa, 'rst tWf G I am very pleased to convey my recognition of the exceptionally fine work of Rabbi Meisels, shlita in his publication for diabetics regarding the shiurim needed to perform the mitzvohs on Pesach. Rabbi Meisels put a tremendous amount of effort into this production, and that effort is OV visible in the finished product. His shiurim, in my opinion, are quite accurate, and may be relied on with confidence. May he merit T continued success in being mezakeh the rabim and spreading kvod shomayim. vru,v ,frcc rgbstc xjbhp ktrah ushsh OM Pesach Y Before eating matzah at the Seder she was instructed to take 3 units of insulin to cover The following list of important issues will about 75 grams of carb. help you plan what to discuss with your doctor and which changes to make in insulin regimen to (Remember, this is only an example to show accommodate the irregular schedule of Yom Tov. you how things CAN be changed around. With the Those on insulin pump therapy will have it much guidance of your doctor everything can and will be easier, since a pump allows for true flexibility with worked out.) all different schedules. Even those who are still on 3) Those who will drink a high alcohol wine for injections, but are following flexible insulin thera- the four cups should be careful to avoid hypo- py (FIT), will have an easier time accommodating glycemia, as alcohol inhibits the liver from pro- changes in schedule. However, those who are still ducing glucose. (This is explained in greater detail on a rigid insulin regimen will need to clearly dis- in our Purim article.) Discuss a reduction in long cuss with their doctor all changes in eating and acting insulin or basal rate with your doctor. sleeping, and decide on necessary insulin 4) The short acting insulin (administered changes. before eating) should only be taken at the time of 1) On the Seder night, take your long acting washing for the Matzah, and not at the beginning insulin at the SAME TIME you would take it on a of the Seder. For practical reasons one might con- usual day. sider covering the carbs of the second cup along 2) On an average day, many people will admin- with the insulin taken for the matzah. This will ister an injection to cover both dinner and snack. not be an option if one is consuming a large Since the Seder will be eaten later than a normal amount of carbs for the second cup. dinner, and only a lighter meal will be served at 5) Matzah may be digested (and converted to the usual dinnertime, one will need to take extra glucose) at a slower rate than challah. Also, the insulin at the Seder. There will also be a need to matzah may be eaten over a long period of time reduce the insulin administered at the regular din- during the Seder. Those on an insulin pump can nertime. Discuss with your health professional do a bolus-n-bite, which means blousing sepa- the exact amount of insulin to reduce at the usual rately for each time matzah is eaten. A pumper dinnertime, and amount needed to cover the can also combine a normal and a square wave Seder meal. bolus. Those on multiple injections should discuss An example: with their doctor how to cover all the matzah by combining Regular insulin and Humalog. This Tziporah, age 7, usually eats dinner at combination would also be beneficial for those 6:00 pm. She takes 3 units of Humalog using grape juice for the third and/or the fourth together with 1 unit of Regular insulin. (The cup, since Humalog given before the matzah may H covers her dinner, and the R covers her be used up by then. bedtime snack.) She eats 60 grams of carb at dinnertime. She also has a snack of 30 6) Some pediatric diabetologists recommend grams of carb at 9:00 pm. administering Humalog after a meal is eaten when dealing with young children who are picky eaters. After discussing with her doctor the This way, the child would get an insulin dose more changes that will occur during the first night precisely matched to the amount of carbs actual- of Pesach, she was advised to eat a snack of ly eaten. This tip can be applied during the Seder 30 grams instead of her usual dinner of 60 when children are tired, and may eat very little. grams. She would only take 1½ units of Humalog, half her usual amount, and no R. 7) Make sure to check your blood sugars 8 to eat matzah according to the Before Motzi Matzah, he should Reminder: Please amounts detailed in this news- check his BG and correct with letter, and to mix light grape juice extra insulin if needed. He should remember that any with 25% water. Since Yankel is then administer 3 units of change in regimen on multiple injections of Humalog Humalog, figuring 4.2 g. for the and Lente, he has the flexibility of second cup (which he already should be discussed eating the way he wants, but he drank); 22+13 g. for the will need extra shots to cover the matzahs (based on the calcula- with your doctor or necessary changes. tions later on in this issue); and health professional. Yankel and his father roughly 15 g. for the kugel. This adds up estimated the timing of the to a total of 54 grams of carbohy- before going to sleep; there may be Seder, and came up with the fol- drates, which would require close unexpected results. If the BG is high lowing: to 3 units of insulin according to and you plan to supplement with extra his insulin-to-carb ratio (1:20). 9:00 First cup = 4.2 g. carb insulin, make sure you have taken any He should also administer 1.5 10:30 Second cup = 4.2 g. carb previous insulin into account. This rule units of Regular insulin at the applies if it is less than 3.5 to 4 hours 10:30-12:00 Matzah = 22 g. carb same time. This would cover the since the last time Humalog was Korech = 13 g. carb 16 g. carb he will consume for administered, or if it is less than 5 to 6 Meal = 15 g. carb (The only carbs afikomen, and the 11.9 g. carb of hours after you took Regular insulin. he will eat will be a 3 oz. slice of the grape juice he will drink (4.2 Please keep in mind that additional potato kugel.) g. for the third cup + 7.7 g. for bedtime insulin doses should be calcu- 12:00 Afikomen = 16 g. carb the fourth), adding up to a total lated with great caution, and follow-up 12:30 Third cup = 4.2 g. Carb of 27.9 g. of carb. (He preferred BG tests should be performed 1:00 Fourth cup = 7.7 g. carb mixing Regular insulin with the overnight to ensure that hypoglycemia Humalog, to administering an doesnt occur. Yankels doctor advised him as extra shot before the afikomen.) follows: [The unused insulin rule should also [Yankels total carb intake at be applied when correcting high BGs On erev pesach, at the usual the Seder will be about 80 grams.] before Motzi Matzah]. dinnertime, he should eat a light snack consisting of 15 g. of carb. He will recheck before going to 8) In the event that Erev Pesach (the Instead of taking his usual 3 units bed (at 2:00) and use the unused eve of Pesach) falls on Shabbos, those of Humalog, the snack should be insulin rule to make sure his num- who eat challah will eat much less than covered with only 1 unit of insulin. bers are in the middle. usual during the night and morning meals. Since the challah would then be At the Seder, few carbs will be consumed until Motzi Matzah. He eaten earlier than usual, most people To prepare your pump would eat a light lunch, or skip lunch therefore need not cover the first entirely. There may be a need to adjust cup or the small amount of pota- for Yom Tov see page 13 insulin. (This is especially vital for toes he will be eating for karpas. those who are covering lunch with a morning shot of long acting insulin.) USE THIS CHART TO DISCUSS You can use the chart on this ALL THE DETAILS WITH YOUR DOCTOR: page to discuss all the details with your doctor: AMT. OF CARBS TIME DOSE/TYPE OF INSULIN An example: Evening Snack Yankel usually eats 45 grams First Cup of carb for dinner at about 6 Second Cup p.m., and covers it with 3 units of Humalog. (He uses a ratio of Motzi Matzah 1:15, one unit of insulin per 15 Korach grams of carb.) Whenever he eats a bedtime snack, Yankel The Meal administers an additional injec- Afikomen tion of Humalog, using a ratio of 1:20. Third Cup Yankel plans his Seder night Fourth Cup carefully and diligently. He plans 9 ing cc (a measure of volume) to grams (the mea- The Kzaisim sure by weight). We therefore used the most strin- (minimum required amount) gent shiur, taken from the sefer "Middos Vshiuri Torah", which the author figured himself using spe- for Matzah: cial tools.