How to Eat Pizza with Diabetes

Pizza may be the single most challenging food for people with diabetes — especially if you use insulin with every meal.

Here’s the problem: When you eat any food that’s packed with both fat and carbs, the fat slows down the absorption of those carbs, making the glucose rise more unpredictable. If you want more details on the science, be sure to check out our article How to Calculate Bolus Insulin Dosing for Protein and Fat. Many sweets and junk foods will cause this sort of blood sugar surprise, but the problem is so significant in pizza, and pizza is so essential, that it’s often called the pizza effect.

Pizza is mostly just dough and cheese and it packs in tons of carbohydrates and tons of fat, a combination that is almost perfectly designed to cause frustrating blood sugar changes. The starch in the dough is guaranteed to send your blood sugar skyrocketing, but the greasy cheese makes the timing of that rise extremely difficult to predict. The toppings don’t help either. For those of us that use insulin with every meal, a healthy and uneventful night of eating pizza can seem to require both advanced calculus and amazing luck.

Whether you have type 1 or type 2 diabetes, pizza really isn’t exactly nutritious. But it is delicious!

How do you handle pizza? Even scientists have tried to tackle the pizza effect. The Diabetes Daily staff have all grappled with the challenge, and more importantly, we’ve got the wisdom of our community of Diabetes Daily readers. We’ve reviewed many comments on our Facebook page and in our Forum on pizza strategies, all from the true world-experts on diabetes: the people living with it.

First, a disclaimer. All of the ideas below, especially those involving insulin dosing, are just intended to get you thinking. This isn’t medical advice. It’s a good idea to talk to a doctor or diabetes educator before making any significant changes to the way that you eat and use medication.

All in all, we’ve identified four major philosophies for eating pizza:

1. “Just Go For It”

Sure, pizza is a potential glucose management disaster. But many of our community members just lean in and go for it.

A warning: It is our job to remind you that high blood sugars are not healthy. After all, they’re basically the root of long-term diabetes misery — hyperglycemia is the single most important modifiable factor in the progression of diabetes and its many tragic complications. And despite all the wonderful new medicines and technology we have to manage diabetes, most people still don’t hit the glucose management targets that their doctors set for them. One night of high blood sugars isn’t likely to do much harm, but many nights, over many years? That’s dangerous.

With that said, some people with diabetes have figured out a way to eat pizza while keeping blood sugar excursions and rollercoasters to an acceptable minimum.

Here are some approaches that people in the diabetes online community have had success with:

Eat your protein and veggies first. The order in which you eat your food can have a big influence on how your blood sugar responds. Filling your belly first with lower glycemic index foods seems to mellow out the impact of the high-carb ingredients you eat next. For some patients with type 2 diabetes, this might be enough to keep a glucose spike within an acceptable post-prandial range. Pizzerias are not exactly known for their diverse menus, but at a minimum, you should be able to find a salad.

If you use meal-time insulin, you have a bigger challenge ahead of you.

Most people with diabetes find that just counting carbs and using a single pre-bolus just doesn’t work for pizza. You might find that you go low first, and then go sky high later. This occurs when the insulin you’ve administered hits the bloodstream before the glucose from the dough does. Then you’ll need to consume some sugar to fight off a hypo, which will just make that late glucose spike even bigger. If you’ve already struggled with this, consider these strategies:

Split your initial bolus — deliver a pre-bolus and then a second bolus sometime shortly after eating. If past pizza experiences have resulted in fast blood sugar drops and/or late blood sugar rises, it may be better to deliver the bulk of your insulin after you begin eating.
Others find that pizza takes such a long time to digest that it is hours before the peak glucose rise occurs. If pizza gives you sticky highs, or very late peaks, consider splitting your insulin dose. Bolus only 50 percent of your total insulin before the meal begins, and the rest an hour or two later. The more closely you can pay attention to your blood sugar — a continuous glucose monitor is key! — the easier this will be.
Take three or four injections for just one meal. Instead of using one injection before the meal and one injection after it, take two or three smaller injections after you’ve finished eating, one every hour or two. When scientists from Penn State experimented with pizza bolus techniques, they found that participants still needed extra insulin 8 hours later.

Insulin pump users have even better options:

Try a dual bolus. Bolus for 50 percent of the meal as you begin eating, and then deliver the rest slowly over the next several hours. In the Penn State experiment, the winning method was when “half of the insulin was given in one dose immediately before the meal, and the other half was administered slowly via the pump over the following eight hours.”
Try a square wave bolus. Release your mealtime bolus slowly over the next two or three hours without a single large bolus at the beginning.

Your body is unique, and the only way to really learn what works for you is to experiment on yourself. Some people have such difficulty with late spikes that they end up with an initial bolus of only about 30 percent of the total carb count. Some deliver most of their insulin an hour or more after they’ve finished eating.

It should go without saying, by the way, that toppings can make this all even more complicated. Whether pepperoni or pineapple, pizza toppings bring their own mixture of carbs, fat, and protein to help make your math even crazier.

No matter what strategy you’ve started out with, be prepared for hours of blood sugar uncertainty. Pizza is notorious for causing long, challenging rollercoasters and sticky highs. Check your blood sugar often, and be prepared to administer correction boluses (or consume some extra sugar) in case things look like they’re getting out of hand.

2. Try a Lower-Carb Pizza

If you can’t say no to pizza, but also don’t want to deal with the blood sugar management headache every time, you should definitely look into the lower-carb alternatives available today.

Make your own low-carb pizza. The internet is chock full of low-carb pizza dough recipes. The king of them all is probably “fathead pizza dough,” which is made mostly with cheese and almond flour — it doesn’t sound particularly healthy, but at least it won’t spike your blood sugar too much. There are other options out there, including a pizza dough made mostly out of ground chicken. You can build a pizza on top of lower-carb tortillas, or low-carb waffles, or who knows what else. Get creative!
Find a restaurant with low-carb pizza. Low-carb pizza hasn’t hit most mainstream pizzerias yet, but you might be lucky enough to have an option in your neighborhood. Perhaps the most beloved in the keto community is Blaze Pizza, which offers a keto crust in its hundreds of locations across North America. The low-carb trend shows no signs of slowing down, and undoubtedly other chains will add keto options to their menus. Call around!
Try a frozen lower-carb pizza. You’re more likely to find a lower-carb pizza crust in the freezer aisle at your grocery store. Quest Pizza is just one of several options you might find. But be sure to look at the carbohydrate count on the nutrition facts panel — sometimes products labeled “keto” or “low-carb” are anything but.
Try gluten-free or cauliflower pizza. These options may or may not be easier on your blood sugar. Gluten-free and cauliflower pizza crusts can still have a lot of carbohydrates in them. But they may have more fiber and lower glycemic-index ingredients, and some diners may find that they’re easier to manage.

3. Use Moderation

It sounds simple: just eat less pizza. Have one slice, half a slice, or even just a bite. Enjoy the flavor, but don’t have enough to cause blood sugar mayhem.

Alternatively, enjoy your full share of pizza … but make it once a month instead of once a week.

Will it work for you? Maybe, maybe not.

There’s a theory out there that we are all either abstainers or moderators. Moderators thrive when they allow themselves small amounts of something — whether that’s pasta, ice cream, alcohol, or anything else that we humans tend to get carried away with. Abstainers, by contrast, are all-or-nothing: They find it much easier to go 100% without something than 99% without it. As the author Gretchen Rubin has explained it,

You’re a moderator if you…
— Find that occasional indulgence heightens your pleasure — and strengthens your resolve.
— Get panicky at the thought of “never” getting or doing something.

You’re an abstainer if you…
— Have trouble stopping something once you’ve started.
— Aren’t tempted by things that you’ve decided are off-limits.

Are you a moderator? Maybe small portions of pizza are all you need to keep you happy. Fill most of your plate with veggies and protein — or treat pizza as a rare meal for special occasions.

But if you’re an abstainer, small portions of pasta might just drive you crazy. In that case, you might consider the final pasta philosophy…

4. Just Don’t Eat Pizza

Abstinence is almost undoubtedly the best way to ensure a night of steady blood sugars. Just don’t eat any pizza.

A large number of Diabetes Daily readers and community members have decided that pizza just isn’t worth it. Some of them have adopted low-carbohydrate diets to help manage their diabetes. Some haven’t — but they’ve determined that pizza is too troublesome to bother with.

As tasty and as satisfying as pizza is, nobody enjoys watching their blood sugars climb up to the stratosphere, especially when hyperglycemia is accompanied by that awful, sticky, brain-foggy feeling. For people that require insulin before every meal, the challenge is even greater, because those big doses of fast-acting insulin are so tricky to time well; a big plate of pizza can result in devastating blood sugar lows as easily as it can frustrating blood sugar highs.

If you pass on pizza, try and fill your plate with plenty of vegetables and leaner protein, such as poultry, tofu, or seafood. That’s a meal that most nutritionists and doctors would happily get behind that should also mean smooth blood sugar sailing.

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