Pizza with IBS, celiac disease or a dairy problem: crusts, sauce, cheese and what to ask

Often, yes, with the right questions. For celiac disease, the key is not just a gluten-free crust but how it is handled: Beyond Celiac advises that gluten-free pizzas be prepared on a freshly washed surface with new gloves and dedicated tools, baked on a pan rather than directly on the oven floor, kept away from the peel used for wheat pizzas, and cut with a fresh cutter. For IBS, the sauce and toppings matter most, since Monash notes that tomato passata may contain garlic or onion. For lactose intolerance, Monash says the harder the cheese, the lower the lactose.

Pizza is a food many people don’t want to give up, so it’s worth knowing how to order it with confidence. This guide covers each part of the pizza in turn: crust, sauce, cheese and toppings.

A pizzeria is a kitchen full of wheat flour. Beyond Celiac notes that flour can stay airborne for 12 to 24 hours and may settle on gluten-free food, and that some restaurants reduce this risk by using dough prepared off-site.

Research suggests this is a real concern. A 2019 study in the *American Journal of Gastroenterology* looked at crowd-sourced results from a portable gluten sensor and found that 53% of tests on restaurant pizza labeled gluten-free detected gluten, compared with 32% of gluten-free labeled restaurant foods overall. The authors point out important limits: people may have tested foods they already doubted, and the sensor can detect gluten below the 20 parts per million threshold used for gluten-free labeling. Even so, it’s a good reason to ask questions.

The BIDMC Celiac Center’s Italian dining handout gives similar advice: ask for a gluten-free crust, and ask how the gluten-free pizza is prepared, including how toppings are added, separate pans and separate pizza cutters.

Our guides to gluten-free vs celiac-safe and eating out with celiac disease go into more detail.

Wheat-based breads are high in fructans, a type of FODMAP, and Monash lists them among high-FODMAP grain foods. Monash suggests that gluten-free pizza bases can be a good choice on a low-FODMAP approach because they contain no wheat.

Keep in mind that gluten-free doesn’t automatically mean low in FODMAPs, since some gluten-free crusts include other ingredients you may react to. Portion size also matters: a few slices may sit well where a whole pizza doesn’t. See FODMAP portion sizes for why.

For many people with IBS, the sauce is the hidden issue. Monash advises asking staff about the tomato sauce, since passata may contain garlic or onion, while traditional sauces are sometimes just tomatoes and salt. For a bianco (white) base of olive oil and garlic, Monash notes it may be possible to have it made without the garlic if ordered fresh.

Garlic and onion are high in fructans, and once they are cooked into a sauce they can’t be picked out. Our guide to hidden garlic and onion explains why garlic-infused oil is treated differently, and what to ask if a pizzeria offers garlic oil.

Tomato sauce can also matter for reflux. Our guide to tomatoes, reflux and histamine covers that side.

Lactose intolerance and milk allergy need different approaches. The NIDDK notes that lactose intolerance is different from a milk allergy, which is an immune system disorder. Milk is one of the nine major allergens under US law.

Monash also notes that softer cheeses such as ricotta and haloumi have a set low-FODMAP serving size, so a white pizza heavy on ricotta may affect you differently from one with a harder cheese. The Monash FODMAP app has the details.

Plant-based cheese contains no lactose, but plant-based products are made from many different bases, and some of those bases are allergens in their own right. Read the label every time, ask staff which brand they use if you can’t see it, and remember that recipes change. For more, see lactose-free vs dairy-free and which cheeses are low in lactose.

Toppings are where FODMAPs and allergens can add up. Monash’s sample food list includes these high- and low-FODMAP vegetables:

• Higher in FODMAPs: garlic, onion, mushrooms, artichoke, red bell pepper.
• Lower in FODMAPs: eggplant, green bell pepper, potato, and plain cooked meats, poultry and seafood.
• Processed meats such as sausage: Monash lists some processed and marinated meats as high in FODMAPs, and BIDMC notes sausage may contain hydrolyzed wheat protein or seasoning mixes.
• Meatballs may contain bread or breadcrumbs, according to BIDMC.

These lists are samples, not complete guides, and your own tolerance matters most. A dietitian can help you work out what suits you.

1. Check the menu online for a gluten-free crust and any notes on how it is prepared.
2. Call outside busy times if you need several changes, so the kitchen has time to plan.
3. Tell the server about your needs, and ask them to pass them on to whoever makes the pizza.
4. Ask specific questions, then confirm the order before you start eating.

• "Is the gluten-free crust prepared in a separate area, with fresh gloves and tools?"
• "Is it baked on a pan or directly on the oven floor? Is a separate peel and cutter used?"
• "Is your dough made here? Is there a lot of flour in the air?"
• "Does the tomato sauce contain garlic or onion?"
• "Could the bianco base be made without garlic?"
• "Which cheeses do you use? Do you have a dairy-free cheese, and what is it made from?"
• "Is there wheat in the sausage or meatballs?"

For delivery, use the notes field for your requests, then check the order when it arrives. If something isn’t right, it’s fine to call and ask for a replacement. See talking to restaurant staff about allergies for more ways to explain your needs.