How to Sugar Surf™ a Pizza

Slices of hot pizza are a true delight for most people of all ages. However, those of us with type 1 diabetes often eat pizza with some amount of trepidation. It may even be a food "to be avoided at all costs". Sugar Surfers see pizza as just another glycemic challenge to dominate.

In this post I will describe how to Sugar Surf a few slices of thin crust pizza. Three to be exact. You will note some methods which may fly in the face of ‘static thinking’ common sense.

In the image, three slices of thin-crust pizza are eaten while I’m trending along a glycemic shelf (a relatively straight BG trend line shaded in green). My “starting” insulin to carbohydrate ratio is 1 unit for 10 grams of carbs. I review the carbs for this pizza (thin crust) and it amounts to 22 grams per slice.

I’m not using a pump. I choose to take 6 units of rapid acting insulin AT THE TIME I start eating the pizza. Why? Because pizza is a “slow” carb food which will not convert to glucose (blood sugar) very quickly. Hence “waiting for the bend” is not usually needed and in fact would result in low blood sugar. If I had started eating this pizza at a higher BG level (>150 mg/dL, 8.3 mmol/L), I would have waited after injecting before starting to eat.

It’s important to note that this pizza had only 4 cheese toppings. If it had been loaded with pineapple slices or other fast carbs toppings, I would have needed to make a difference decision. But it was what the restaurant called the “Quattro”. I added black olives only (no extra carbs).

I anticipate that the slow digestion of these three slices of pizza would be a gradual process. And I’m correct. The fat and protein in the food slows stomach emptying and delays digestion of the meal into glucose. The 6 units of insulin lispro (Humalog) maintains my glucose levels for almost 2 hours without dropping it excessively. At about 1 hour 45 minutes, a delta wave (red triangle) begins. The upward inflection of the red delta wave is telling me the blood sugar raising effect of the pizza is now overpowering the 6 units of insulin injected almost 2 hours earlier. Once I am comfortable in the knowledge that my 6-unit meal bolus was “fading” while the pizza continued to be digested into glucose, I chose to take a secondary (follow up) rapid-acting insulin dose to “pre-empt” the impending BG rise. Then, about 25-30 minutes later, my BG peaks at 144 mg/dL (8 mmol/L) and pivots downward.

What was totally counterintuitive to the non-Sugar Surfer was administering a second rapid-acting insulin dose when my blood sugar was only 113 mg/dL (6.3 mmol/L). However, seeing the delta wave, KNOWING my first insulin dose was now fading, and KNOWING I had eaten a slow carb meal (pizza), made taking a second “pre-emptive” insulin dose very logical. Also, I’ve found that “second” doses are usually smaller than the first. Usually by 25-50%.

After the glycemic pivot at 144 mg/dL (8 mmol/L), over the next two hours blood sugar came back into range and inflected into a steady trend line (green shelf). So…in total, these three slices of thin crust pizza with a four-cheese topping required about 4 hours of insulin activity to properly metabolize and dispose. Sugar Surfers know that a single rapid-acting insulin dose by injection only covers the blood sugar raising effect of food for a short period of time. If all the insulin used in this example had been taken at once, then a low blood sugar after 60-90 minutes would have been a likely result.

What if I had eaten five slices of thick crust pizza with different toppings? Perhaps a third dose would have been needed two hours later. Understand that in every situation, there is always some need to experiment and observe carefully what follows. This is at the heart of Sugar Surfing.

This example doesn’t illustrate how an insulin pump would address this situation. But had I worn a pump, then a dual-wave (combination) bolus would have been my best option. Perhaps 5 units immediately and 5 units over the next 4 hours. But this would take some trial and error to refine.

Any meal with a higher percentage of fat and protein (like pizza) alters insulin needs. This makes the insulin to carb ratio and insulin sensitivity (correction) factors you use a bit unpredictable, but not totally undefinable. It takes time and practice. Sugar Surfers know that pre-assigned insulin dosing “factors” are just starting points for dosing. As you can see explained above, there are other things to consider when dosing insulin for meals (amount AND timing). In short, these include the blood sugar level, trending direction of the BG, carbs to be eaten, complexity of those carbs (now much fat and protein are mixed in) and even activity level (sedentary vs active).

Sugar Surfers know that no foods are truly “off limits”. However, Surfers are not reckless. While they can manage just about any glycemic challenge, they don’t challenge themselves needlessly.