Scott Benner 9/22/25 Scott Benner 9/22/25

#1634 Grand Rounds: Inhaled Insulin

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Pediatric endocrinologist Dr. Michael Haller explores inhaled insulin and the evolving approval process for children under 18.

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Welcome back, friends. You are listening to the Juicebox podcast.

Dr, Mile Haller 0:15
Scott, good morning. Thanks for having me on I'm Dr Mike Haller. I'm chief of pediatric endocrinology at the University of Florida. Story is a long one goes back to desire to be in medicine as a child. My grandfather, living with type one diabetes, was also part of the inspiration.

Scott Benner 0:33
My grand rounds series was designed by listeners to tell doctors what they need, and it also helps you to understand what to ask for. There's a mental wellness series that addresses the emotional side of diabetes and practical ways to stay balanced. And when we talk about GLP medications, well, we'll break down what they are, how they may help you and if they fit into your diabetes management plan. What do these three things have in common? They're all available at Juicebox podcast.com, up in the menu. I know it can be hard to find these things in a podcast app, so we've collected them all for you at Juicebox podcast.com. Please don't forget that nothing you hear on the Juicebox podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin.

The show you're about to listen to is sponsored by the ever since 365 the ever since 365 has exceptional accuracy over one year, and is the most accurate CGM in the low range that you can get ever since cgm.com/juicebox us med is sponsoring this episode of The Juicebox podcast, and we've been getting our diabetes supplies from us med for years. You can as well us med.com/juicebox or call 888-721-1514, use the link or the number get your free benefits. Check and get started today with us. Med. This episode is sponsored by the tandem mobi system, which is powered by tandems newest algorithm control iq plus technology. Tandem Moby has a predictive algorithm that helps prevent highs and lows, and is now available for ages two and up. Learn more and get started today at tandem diabetes.com/juicebox

Dr, Mile Haller 2:29
Scott, good morning. Thanks for having me on. I'm Dr Mike Haller. I'm chief of pediatric endocrinology at the

Scott Benner 2:34
University of Florida. Oh, wow. How'd you get that job?

Dr, Mile Haller 2:37
Well, story is a long one. Goes back to desire to be in medicine. As a child, my grandfather, living with type one diabetes was also part of the inspiration. Then working with some of my mentors here at the University of Florida. Early on in my career, even in high school, I was had the opportunity to work in the lab on some of the early diabetes prevention trial work where we were learning that auto antibodies can be used to predict type one. Then I went off to college at Duke, and came back to UF for medical school and went to diabetes camp. And diabetes camp was the final sort of nail in the coffin for me in terms of pathways. It was pretty clear after that experience that I wanted to be a pediatric endocrinologist. And then I've been here at the University of Florida. My entire academic career, started as a assistant professor and then worked my way up, and almost nine years ago, took over from one of my mentors, Janet Silverstein, as the

Scott Benner 3:30
Division Chief. What was the experience at camp that made you feel that way? Well, I was always

Dr, Mile Haller 3:35
just really enamored with kids and being in in the care of young folks, so I kind of knew I was going to likely lean towards being a pediatrician, but the 24/7 experience there is what really did it for me, just seeing what living with type one is really like, being with these kids, doing all the things that you do at camp, going out on the lake, going to do archery, playing land Olympics, getting up at 2am in the morning with them to check glucose, as this was in the era where we just had glucose meters and an NPH in regular so didn't have nearly all the tools we have today. And that experience was definitely transformative for me, just wanting to have relationship with those kinds of kids going through those struggles and helping them find a way forward to live their best life with diabetes.

Scott Benner 4:22
Would it surprise you to know you're not the first endocrinologist to tell me

Dr, Mile Haller 4:26
that? Not at all? Yeah, I think diabetes camp is actually our, probably our strongest single recruiting tool for convincing young medical students or physicians to have a interest in it. It's why, it's why I actually require anybody who wants to come shadow with me to volunteer at camp, because I think a you can't really know what it's like till you've seen it in that setting. Sort of been with a person for a week, 24/7, and B, just that that experience tends to be so transformational, foundational for people, that it captures some folks who otherwise wouldn't have been interested. The field.

Scott Benner 5:00
Is it true that a lot of times people want to be endos, but they almost get saddled with the diabetes? Is that why you have to make them interested in it like, you know, I'm saying that they're more interested in other endocrine specialties, but because they're the endocrinologist, they handle diabetes as well. Is that? Is that a thing, or is that something I've just heard that isn't true.

Dr, Mile Haller 5:22
I think that's probably true in the adult side, on the pediatric side, since about 50% of what we do is diabetes care, more than not actually, the folks who come into endocrinology on the pediatric side are interested in diabetes care management in some significant way, even if that's not their core academic pursuit or what they become, sub sub specialist expert in our place is a little biased, because we're such a well known, strong historical type one diabetes clinical and research center that most of the folks who come train with us already have that desire to be in that space, but it is a harder sell. Unfortunately, diabetes care requires a whole lot more team members, is therefore more expensive to provide. Well, isn't super well reimbursed. And so, you know, in terms of running a business for people outside of academics, it does make a lot more sense to focus on the endocrine side of things, standard endocrine and not do the diabetes care. So in the adult world, that's that is a common thing. There are lots of endocrinologists who don't do diabetes at all. The pizza that's not, not very common

Scott Benner 6:27
at all. I see, can I ask a couple more questions before we get to the inhaled insulin? Yeah, of course, this is interesting. So I did a series a couple of years ago. We called it grand rounds, and we went to So Mike, you don't really know a lot about me. That's fair enough. I have a private Facebook group that supports the podcast that as of this recording, has 72,000 active members in it. I went to those people and I said, Let's make an exhaustive list of what you wish would have happened at your diagnosis. And that list turned into what they wished would have happened and what they wish wouldn't have happened. And I think we put together about 90 pages of notes from people and responses, and called them down and, you know, put them together and created this, I think, about seven or eight part series. It was really aimed at physicians to say, like, look, this is what people said. You know, their experience was almost like them filling out a survey after after service, and I found that the series also served for people listening to say like, well, this is what I should be expecting from myself, or here's the things I should be looking for. And we kept it going by bringing in endos to talk about what their experiences were. So I'm going to ask you the question that I asked them, and very simply, I want to know what you think endocrinologists need to be doing, should be doing to make the experience better for people. And what do you guys find yourself sitting across from the patients wishing that they would do to make the whole thing be smoother?

Dr, Mile Haller 7:53
Yeah, that's a great question. I think at diagnosis, a lot of it depends on where the family is coming into the diabetes space, and and physicians providers need to do a better job of recognizing that there are big differences, you know, than somebody who has nobody in their family with diabetes and comes in DKA and they're worried about their kid making out of the ICU, let alone understanding what a CGM or a pump is, versus somebody who's, you know, got a parent with type one or sibling with type one is picked up by way of antibody screening, and, you know, is never even symptomatic at the time of their diagnosis. So I think that the heterogeneity of presentation is becoming even more broad as we pick up more and more people pre clinical and physicians need to understand that that heterogeneity is part of doing a better job of presenting what people need to know at the right time to make that transition to life with diabetes easier. And I've erred in this before, personally, so I'm not suggesting I do it perfectly. I think listening and hearing people's story. Instead of jumping right into everybody who gets diagnosed needs to know x, y or z in this order, is really helpful. Probably what physicians need to hear is remember, and this is true in every part of medicine, is remember to listen before you go in and talk, and then take that information in before you figure out what you're going to say, and then help use that to guide the conversation. I think something that our team does really, really well, though, is tell folks from the very day of diagnosis that you know, we're all part of a big team here to help you, the patient, manage your diabetes. And it's different than, you know, almost every other diagnosis out there and in that, you know, we serve as coaches, but you, at the end of the day, are the player on the field of the sport, and you've got to make the, you know, the day to day, minute to minute, game time decisions. Our job is to give you the skill set to do that as well as humanly possible. Yeah. And I think when we set that philosophical tone from the beginning, it really helps our patient. And families sort of embrace that, so that in our goals, by the time they graduate from our pediatric clinic, they frankly, don't need us or their adult endocrinologist for much obviously, they still have to have them to write prescriptions and help with some of the screening for complications and obviously giving medical advice when it's necessary. But the reality is, we haven't done our job well if we aren't putting young adults out into the world who can do all this really well without anybody's help.

Scott Benner 10:26
Yeah, I have to tell you that. So this podcast has been it's 11 years old. It has over 1600 episodes. It's been downloaded over 20 million times. It charts in 48 countries around the world, and I think that that's because I started making a podcast in 2015 and we used to tell people, like, everything you need is in those episodes. Like, just listen and you'll and by the way, Mike, this is there's no no BS. Like, if you just listen to the podcast back then you'd wake up with a 681 say, at some point it was that all the answers were in there, but, you know, they weren't. They weren't on a bullet list. They weren't like, learn this, then learn this, then learn this. It was sort of what I got out of it was just kind of what you were just saying, is that there, there, yes, there's tools, right? And I need to know what they are. But how am I supposed to guess which one you need right now? Like, where are you on that journey? What's the thing you need to hear today? And that what the podcast allows is for people to jump in and out of it, at their leisure, at their home. And I think the limitation of going to see your doctor is very much that it's, you know, if you're lucky, a half an hour four times a year, and you know? And if you have something in your head the day they show up, and it's not the thing they need, I mean, there you go. It's six months between meaningful interactions. Again, I don't know how you're supposed to do the thing you're supposed to do. It really is incredibly difficult. Eventually we were able to put together, you know, the podcast had gotten so large that I was like, Well, I can't just keep asking people, just keep asking people just listen to 400 episodes like, you know, like, at some point it became ridiculous. So I took what I thought were my foundational ideas, and Mike, I want to be clear, just the guy who started writing a blog when his daughter was diagnosed in 2006 I have no medical background, no training, but what I realized was I was a stay at home dad. I figured out how to take care of my daughter, and one day I realized that I had all the tools and all the ideas that I needed to keep her a 1c in the fives, actually, that diabetes no longer felt like unknown to me. Things happened. I knew what to do. I knew how to react this thing that you were describing earlier, and I sat down and very thoughtfully put together what I thought were the, you know, the hallmarks, the bedrock of this idea. And I contacted a friend of mine, Jennifer Smith. She's a CD ces works for Gary at Integrated Diabetes. You might actually know her. And I said, I have these foundational ideas. I want to put them in a series. And we made something called the diabetes Pro Tip series. And now what people say is, I grab the list, I listen through it at my leisure. My a, 1c, ends up in the sixes. So many people are angry at their physicians because they feel like I have a question. They don't know the answer. They don't listen to me that what you just said. I just think it's an unfair paradigm, like, I don't know how either of you are supposed to succeed in that setup. Let's talk about the tandem Moby insulin pump from today's sponsor tandem diabetes care. Their newest algorithm control, iq plus technology and the new tandem Moby pump offer you unique opportunities to have better control. It's the only system with auto Bolus that helps with missed meals and preventing hyperglycemia. The only system with a dedicated sleep setting, and the only system with off or on body wear options. Tandem Moby gives you more discretion, freedom and options for how to manage your diabetes. 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Dr, Mile Haller 15:32
Yeah, I agree with you. I think Aaron Kowalski from breakthrough T 1d once you know, did this analogy that really struck me, which is that, you know, patients spend less than 30 seconds on a 24 hour clock of their diabetes time with their provider. And when you think of it like that, like, of course, it's, it's not a fair fight, in that sense, of trying to impart all the wisdom we need to give to patients and families to do well. And I think that's why families need the kind of things that you put out in the world, and why they strike home so strongly, because people are yearning for access to information that's accurate, that that speaks the same language they do, that doesn't have sort of any bias, necessarily, from a physician, and they don't feel judged by listening to or, you Know, trying to impart So, yeah, yeah. I think that's why everybody with type one lives that that unique experience and and why it's so important that there are resources, you know, like amazing podcasts and like social media chat groups, which I try to be in a lot of, because I find out i That's where I do a lot of sort of nowadays. That's my version of active listening, I just see what people and patients and families are writing about, thinking about saying, you know. And sometimes I interject because I see something that I think is really, really incorrect. But more often than not, I just listen by way of reading, because it helps me when I then see the next patient in real time to hopefully appreciate better what it is they might be thinking or going through, or the question they are uncomfortable to ask, and I can try to impart some wisdom to help

Scott Benner 17:05
them. One of the most valuable tools I have is that community, because you know, where people's like, I don't know how I hear from people all the time. Like, the podcast always seems to have the topic or the answer that I need, and I tell them all the time like, Yeah, I'm watching 70,000 of you talk to each other, I know where you're struggling like I know where the pain points are. And it's because of you that I understand what content it is you're looking for, what answers or ideas that that you're lacking. Anyway, it's just, I think I bring all this up because that toolbox, from what I understand from everyone who's tried inhaled insulin, that toolbox would be really enhanced by being able to break a 250 or a 300 blood sugar, even if you didn't use inhaled every day all the time, if you just had it with you for those high blood sugars, that it might be a significant reduction in Stress and time spent dealing with diabetes. I don't understand inhaled insulin enough. I can tell you, I've had people on it, on the podcast, who use it. Who are they proselytize about it. They love it so much. But every person I've ever interviewed struggles to explain it to me. It's tough to sell something when a person who loves it and tells you that it's amazingly beneficial for them. And I say, okay, so how do I dose it? And they go, I know, two of four and eight. Like, I'm like, I'm like, Yeah, you know, like, you're not selling it anyway. You're you're on today because inhaled insulin. What have they done? They're doing research for a younger segment of people, right? Can you tell me more about that?

Dr, Mile Haller 18:38
Yes, I had the pleasure of being the lead the principal investigator for the inhale one study, which was the study designed to try and get FDA approval for inhaled insulin in the pediatric space. It's been approved in adults for quite some time, and there are many pediatric and adult endocrinologists who prescribe it in the pediatric side. It's, you know, it's currently still off label, but much of what we do in pediatric medicine is off label, just because it takes pharma companies much longer to get those studies done. Yeah, and you're right, it is a very different paradigm to use inhaled insulin. And so it does make it, I think, harder for people to describe it sometimes to folks who are? You know, taught from day one that this is how we get insulin. It's through a needle and syringe or a pump, and this is what basal is, and this is what Bolus looks like, and these are carb ratios, and these are correction scales. All that gets a little fuzzier with with inhaled insulin, and so it requires a reframing of thinking about how you're going to use it and when and what situations, but your initial analogy, I think, is absolutely right. I think it's just one more really nice tool to have in your toolbox, one that I think many more people living with, type one should have and should feel comfortable understanding how to use. And if they did that, you know, they would see that it serves an important purpose. And. And we we get through to more folks. I think the first step to doing that is just convincing more providers out there that it's an important enough tool that they should be using and trying with their patients. I think because of the previous historical commercial failures of some of the earlier inhaled insulin products, it's just been hard to break through that, that sort of shell for physicians to say, I'm going to try this different paradigm, because people are comfortable with what they know, and getting people to do something new is always hard. This, this idea of therapeutic inertia is a very real thing in medicine. And so you've always got, you know, some of your early adopter kind of people, which I usually am, in that category, so I'm always excited to try these new things. But there's the larger majority of folks who absolutely are are not going to do anything until they see many more of their colleagues using it and having success with their patients. Yeah,

Scott Benner 20:52
it's interesting that there are spread out across this country, there are nurse practitioners and endos who will look their patients in the face and go Listen, go listen to Scott's podcast. And in that same world, there are people who would say, I would never, ever suggest anything like that to a patient. And I think it always does boil down to that what you just said, there's some people are kind of like they're out on the, you know, out on the edge of the surfboard. And there are some people are in the back waiting to see everything flatten out before they'll say, yes, they they're risk averse in a way that, and I'm not saying you shouldn't be risk averse, especially in medicine. There's a tipping point in there. I don't know where it is exactly, but you have to try new things, like right now, I think I've been well out ahead of this for a couple of years now. But GLP, ones for people with type one are incredibly valuable for those of them who have insulin resistance. Yeah, absolutely, yeah. That's how I'm seeing it coming back to me. Like, if, if you have type one diabetes and no real like, insulin resistance issues, like, you know, anything that would make you look type two if you weren't type one, I don't see people having as much benefit there. Those that have the trouble a reduction of 2030, 40% of their insulin is not uncommon, and I've seen people have conversations right on this podcast of there are two great episodes with the mom of a young girl who should type one for four years, using like 5060, units of insulin a day, starts gaining weight. The mom had had PCOS and was put on a GLP one for weight, and PCOS, she saw it really help her. Thought she was seeing her daughter having PCOS symptoms, got the GLP to her, and, no kidding, had to take their pump off. Was using like a unit of injected basal a day for a long time. Now, you know, is it gonna stay like that forever? It's not, and they're seeing a trend in the other way, but it lasted for years, like there's gotta be something to learn from that, you know, and I think with the inhaled insulin, like the same idea, like, because I still see people running around going, well, glps are not for type ones. I saw a very respected person in the diabetes space, somebody I respect, who's been around forever and ever, one of the smartest people I've ever said, just kind of like philosophizing out loud today, like, these GLP ones might have some value for type ones. I'm like, You're not just in the obvious, yeah, wow, wow. You're not just in the caboose of the train, right? Like, you're back at the station, like looking up, going, like, I think I might be seeing a train up there. That's a person who's a thought maker with the inhaled, yeah, I guess what I'm wondering is, is, when you go to another, when you go to a colleague and say, Look, you should be learning about this and giving it to people, when they push back, what do you hear them pushing back on? You've probably heard me talk about us Med, and how simple it is to reorder with us med using their email system. But did you know that if you don't see the email and you're set up for this, you have to set it up. They don't just randomly call you, but I'm set up to be called if I don't respond to the email, because I don't trust myself 100% so one time I didn't respond to the email, and the phone rings the house. It's like, ring. You know how it works? And I picked it up. I was like, hello, and it was just the recording was like, you asked. Med doesn't actually sound like that, but you know what I'm saying? But you know what I'm saying. It said, Hey, you're I don't remember exactly what it says, but it's basically like, Hey, your orders ready? You want us to send it? Push this button if you want us to send it, or if you'd like to wait. I think it lets you put it off, like, a couple of weeks, or push this button for that. That's pretty much it. I push the button to send it, and a few days later, box right at my door. That's it. Us. Med.com/juicebox, or call 888-721-1514, get your free benefits. Check now and get started with us. Med, Dexcom, Omnipod, tandem freestyle, they've got all your favorites, even that new islet pump, check them out now at us, med, Comm, slash Juicebox, or by calling 888-721-1514, there are links in the show notes of your podcast player and links at Juicebox podcast.com to us, med and all of the sponsors.

Dr, Mile Haller 24:54
I think there have been a number of barriers to it that are sort of systemic. Of. US healthcare. So certainly in the pediatric endocrine world, when things aren't FDA approved, that puts up a barrier. There are some physicians who just won't prescribe it, and patients and families who won't feel comfortable. And I understand that, but we've now not quite yet, but we've effectively taken that barrier away. The clinical trial we just completed, you know, showed that for all practical purposes, inhaled insulin is non inferior to injected rapid acting insulin in the basal Bolus setting. And to your point about GLP ones, it was associated with lower weight gain and improve patient satisfaction. So if you got those things, why wouldn't you consider it as an important tool? But because historically, insurance coverage has been more challenging for non FDA approved things, it's created a bit of a disparity where you have only families who could afford to get inhaled insulin and pay for it or figure out the logistics of getting it directly from the manufacturer when they were offering it at a discount, has led to just it not being used as much. I remain very hopeful that, you know, as it works its way through the FDA approval process and kids, that that barrier will go away, and people will have more opportunity to try it. And, you know, the offices will receive samples, because pharmaceutical companies won't bring samples for things that aren't approved, you know, to a pediatric office. So I think all those things are going to help it get past that, that big hurdle. I think it was just lack of awareness and understanding, you know, it is the fastest acting insulin we have, objectively, by quite a bit. It because of you inhaling this, you know, this biomaterial technosphere that regular human insulin is bound to it goes into the lungs. It disassociates with the pH change, and the insulin is absorbed within a couple minutes. You know, take sub q insulin 15 minutes on a good day to even be detectable in the bloodstream. Inhaled insulin is in and working and peaking in almost that same time frame, and is completely gone within 3045, minutes. Is the other big advantage. So you don't get that tail effect like you get from inject. From injected insulin, right? So it has so many sort of use case advantages that I really think it's just getting people past that inertia, that therapeutic inertia, of trying it, using it, you know, getting those barriers out of the way so that they will, will try it, I think will, in this case, you know, finally lead to success.

Scott Benner 27:19
Could this be like a beta, Max VHS thing. Are you too Am I too old? Are you young? You old enough to understand that reference

Dr, Mile Haller 27:25
I am, although I use that, I use that analogy all the time with patients, when I'm talking about CGM, and I say, you know, imagine telling me your favorite movie with an old VHS tape versus a Blu ray Disc. And they look at me like they don't know what either those things are anymore, because everybody stream stuff, yeah, as I'm just writing CDE CGM is more like using a Blu ray and then checking blood glucose with a meter, was more like six still frames on an old VHS tape. But, yeah, I think it's just technology uptake. It's moving with the times. It's getting past, you know, enough people with experience and and comfort with it that that it reaches the critical mass, and then it will take off. More

Scott Benner 28:01
Well, Mike, I sort of more meant that back I'm 54 So back when, like before, BCRs, people are like, I don't even know what that is, but you didn't used to be able to watch something that was recorded in your home. And there were these two competing ideas. Betamax was one tape. VHS was the other. VHS was bigger. It didn't look as good quality on the screen. Beta Max was smaller. It looked better. And for reasons that I don't know that anybody completely understands, the public drifted towards VHS and Betamax went out of business. Oh, yeah, right, yeah.

Dr, Mile Haller 28:33
No, that kind of thing that plays into, Sorry, I misunderstood the analogy you're making. Yeah, I think it's just injected insulin has such a stranglehold on the psyche of how you manage diabetes that even when offered something that has objectively advantages over it, people kind of shrug their shoulders and say, no, no, this is how we manage type one. We're going to stick with this stuff, right? This is faster, easier in some ways, to take doesn't have some of the risks associated with it, and yet people still choose the VHS tape to your point. So, yeah, I think there's going to take, take some work to get people to get

Scott Benner 29:06
past it. What are some of the risks that it doesn't carry?

Dr, Mile Haller 29:09
You know, I think really that's that post injection hypoglycemia that a lot of, certainly young, active people see around sports that it really helps reduce the risk of those exercise induced insulin potentiated hypoglycemia, because inhaled insulin is in does its glucose lowering and is out in such a short period of time, you can send your young athletes out on the field with a Normal blood glucose not worrying that you know their lunch injection from two hours ago is going to keep pushing them further and they're going to plummet and have a hypoglycemic event out on the field. So it really has have an advantage in that kind of situation.

Scott Benner 29:51
So in a very specific use case, your kid comes home from school and has soccer practice at five. Child's incredibly hungry. You're not going to tell them, Look, we don't want active insulin during soccer practice, so don't eat. We'll eat after you don't do that. So you feed them, you give them the insulin. They go upstairs, they get changed. You drive them to soccer practice. They're running around. They have a ton of active insulin, and they crash low. Now they're eating bars and drinking Gatorades and having a bad time. You're saying if they eat that same meal and took insulin, inhaled that by the time they got the soccer their blood sugar would be stable, the food would be handled, and there wouldn't be any active insulin to make them low while they were running

Dr, Mile Haller 30:29
around. Well, I can't promise that meal coverage would be part is definitely yes. That's the idea. The latter part is absolutely true. The lack of active insulin on board is just huge, a safety advantage in situations where we know you go out there and exercise and any insulin that hasn't been vascularized is going to get there much quicker. And kids tank all the time, and it's a huge distraction. It affects their performance. It forces them to take on extra calories that they may not want to. They feel full and bloated because now they've chugged a juice, you know, a protein bar or something. So, right? It definitely has those advantages. I think the challenge is just getting people to kind of work around the different paradigm, you know. So because the inhaled insulin only comes in currently, four, eight and 12 unit cartridges, and the units, unfortunately, don't equate to injectable insulin units. It just takes some time to get used to the notion that, you know, the inhaled insulin units you need two, if not three times more, to equate to the same injected amount. And I wish we could sort of call them different, different things. So we refer to them as a phrase of units when we talk to patients and families, and we did that in the study. And that always takes people a while to get used to, get used to, because, you know, nobody wants to suddenly take three times more insulin than they're used to. And again, it's not really that much more insulin. It's just the way that the units are. The numbers counted when you give it inhaled, but, but yeah, you know, if you're willing to give an inhalation and you're willing to top it off, so to speak, you know, every couple hours, you can really see a marked reduction in glycemic variability, far less risk for hypoglycemia. And so, you know, I think the sports case is just one really good use case, right? I think really pesky highs from challenging meals is another one. So you know, you're out eating your Chinese or your pizza, notoriously, requires, you know, three or four boluses or a square wave or dual wave, you can effectively, you know, approximate those things with inhaled insulin, just by literally watching the rate of change of your CGM. And so it requires patients who are willing to put in a little bit of that work to kind of notice that. But if you're an attentive person, and, you know, nowadays, almost everybody wearing a CGM can see their arrows in real time. And you just start to redo when the arrow starts to change its direction, and you see it blunted back to a flat or, you know, a downward trend is quite remarkable. You really just can't do that with injected insulin, because by the time you wait for the arrow to change, you know, everything's already happened, good or bad, and so it gives another significant timing advantage in those kinds of settings that I just don't think what you can't achieve with injected insulin. So I'm not suggesting that the inhaled insulin is going to replace injected insulin for everybody. That's that's just not likely to happen. But there are all these use cases where I think it can be, you know, an important tool and toolbox to help people achieve better control, you know, to wake up with those agencies in the low sixes, like you said, without, you know, having to fight as many battles with diabetes as everybody living with a disease knows, is just the reality of it. It just makes things a little bit easy if you have that extra school skill set.

Scott Benner 33:38
Yeah. Is it possible? You already outlined the problem when you started talking, because you said, we, you know, give people tools. You can give them their scripts and everything, but in the end, they've got to go home and make a decision to actively be part of this. I mean, maybe that's it just there. If you have to do all the things that you just said, to learn how to use it and to figure out where to put it in the right situations and everything. Like, maybe that's just the bridge too far already, like, maybe the VHS of it all is that, you know, a ID systems are, you know, it's one insulin. I don't have to mess with different versions of insulin. I put the pump on, the algorithm makes the decisions. And, you know, it's not perfect, but I'm also not involved all the time, and I don't need to understand this like a science experiment, like, I wonder if that isn't maybe just the simplicity of why usage isn't being done more. I think it's simple to say, like people are scared to put stuff in their lungs, because that is the first thing that scares me about it. But I'm also assuming that you wouldn't be here talking about it if you hadn't seen it be very successful for people and not an issue. I know there are some people who get that cough and stop, but that's not overwhelmingly what happens. Am I right about that?

Dr, Mile Haller 34:47
Yeah, so the safety issue is one that commonly comes up, but is has been pretty well put to rest in all the studies. There really is not any concerning safety signal. In fact, in the pediatric study, the. That the pulmonary function changes that everybody sees with inhaled insulin were actually more significant in the group that was randomized to injected insulin than it was in the group randomized to inhaled insulin. He would have presumed it was the other way around, perhaps, if he thought there was an issue with with the inhaled insulin causing any any issues, the long term studies so far really don't show any concern unless, of course, you know you're a smoker, or have known pulmonary disease, like, you know, recurrent asthma, that's severe, then that wouldn't be a good choice for you, right? But, yeah, that you know that too is a barrier for people to say, I'm willing to try this new thing. Yeah, I think you know you're right. The other things that we have now do a pretty darn good job, if you use them appropriately, but not for everybody, in fact, not for a majority of patients who still aren't getting to goal. So I think we always have to be striving to generate new tools to hopefully get, you know, even a few more percent of the population across to the, you know, to the desired side of the A 1c threshold for reducing their complications, and an inhaled insulin can definitely do that for folks. I mean, there are, there are definitely patients for whom they are using a basal insulin and inhaled insulin as their only rapid acting insulin. And they take, you know, inhalations, you know, before each meal, an hour after each meal, and in between those meals and snacks to correct. So they might be taking, you know, eight, nine inhalations a day, but they don't have to do nearly as precise carb counting, because it's a bit more of a paradigm. They it's more like sugar surfing by giving a little bit more when the, when the, you know, the arrow directionality changes, or certainly, if the number is higher, is that modality going to work for everybody? No, it's just not. But definitely works for some, and I think it would work for many more who were given the opportunity. The other things I'm really excited about in terms of use cases are, to your point about pumps, are using inhaled insulin in combination with the pump algorithms. So we all know that the, you know, the biggest reason the current algorithms don't get us to goal as well as we'd like is that meal coverage is just not optimized. The insulin is not fast enough to do meals right? But if you had a Bluetooth enabled inhalation device for your phrase, and you could essentially announce a meal by way of giving, you know, a single, four, eight or 12 unit cartridge that you didn't even really think about dosing on. You just knew every time I'm going to eat, I'm going to give this little bit of inhaled insulin. I'm fairly confident that in the next few years, the algorithms would be able to do the rest of the meal work without you having to do much of anything. And so I think that's a place where I'm already seeing patients do that. And I think that could be come sort of a commercially available use case for inhaled insulin over time.

Scott Benner 37:44
It even occurs to me that with the aggressive nature of some of the DIY algorithms, like you maybe wouldn't even have to announce the carbs right, like you'd let the inhaled handle the spike absolutely right, and then let the algorithm mess with whatever drift you see. That's

Dr, Mile Haller 37:59
right. I was just having that exact conversation with the patient I saw this morning before I came over to do this podcast, and he's on a T slim and was interested in how he could further optimize his meal control. And while that algorithm does a pretty darn good job overall, you know, he asked that exact question, what would happen if I if I took inhaled insulin and then didn't do anything? I said, you probably get about the same results as you're getting now. He said, Well, that would be a lot less work. Less work for me. I might be interested in trying that, right? And so I think exactly as you're suggesting, as we start to evaluate, you know, the safety, the clinical outcomes, and then the mental burden, which, at the end of the day, I think, is still the biggest thing that people living with diabetes have to deal with day in, day out. You know, if I can do something that gets me the same result with less burden, and I can think about all the other things in the world I'd like to do that don't define me as a person living with diabetes. I think that would be great for most patients. So I just think that's another space where inhaled insulin has got an opportunity to make a difference.

Scott Benner 38:54
Yeah, this is the first time I'm seeing it like in my mind, like my daughter's using trio, just so you know which one I'm what algorithm I'm talking about. But what I'm seeing is, if the inhale takes 15 minutes to peak, and basically food takes 15 minutes to hit you. You sit down, you inhale the insulin, you eat, maybe you tell the algorithm I had a few carbs, like, just give it like a number, so that it knows food is happening, but not enough of a number that it's going to make an aggressive Bolus, and then it'll address the drift up if it sees one like, I think there's a way to game that up and make that work. I mean, I bet you people could figure that out as they were going but no matter what algorithm they're on, actually

Dr, Mile Haller 39:34
agreed. But like, to your point, that will require some tinkering and people figuring out what works individually for them, depending on which algorithm or DIY system they're on. And they're definitely people who are doing exactly as you just described, and finding that it works well, because the, you know, the pharmacokinetics and pharmacodynamics of that little hit of super rapid acting insulin, you know, inhaled and then the pump system following up with the rest to clean up what's left. Shift works quite nicely, and again, still reduces the risk of that post meal tail insulin causing a low in any situation, whether that be exercise induced or even just hanging out watching a

Scott Benner 40:13
movie. Mike, you alluded to something a minute ago. I'd like to go back to I think that it's lost, maybe on people listening to a podcast about diabetes, people who either are already seeing a one season, the sixes or the fives, or have goals of it and are moving towards it. But that's not most people's reality, right? Like, if, if I said to you, you know, take 100 of your patients, you know, what percentage of them have an A, 1c, over nine? Do you know what I mean? Like, like, how many people aren't playing the same game that you and I are talking about right now?

Dr, Mile Haller 40:43
Yeah, I think there's like, sort of three distinct populations of people. There's the folks who are just struggling so, so hard with their diabetes. They aren't able to adhere to whatever regimen we suggest, that their agencies are, like you said, above nine. And sadly, you know, that's still in our clinic, probably about 20% of the population. So that's a lot of people, yeah, and so any tool we can use to get them down is meaningful. So, you know, we we've had many more conversations in our group now about offering the islet system to those patients, because for them, we know it will get them down to an A, 1c in the mid sevens. Is that where we want them? You know, no. But is it a lot better than their double digit, a, 1c Absolutely. We have to sort of shift our thinking to what works for the patients in those populations.

Scott Benner 41:24
When I interviewed somebody from beta bionics, I said I would probably skip right over endocrinologist office and go right to GPS and just tell them, like, hey, you know, all the people you have with type one diabetes or have, you know, double digit a one sees, like, slap this thing on them, give them a seven.

Dr, Mile Haller 41:38
Yeah, it's funny, you mentioned that. So we, we here at UF and also with our colleagues at Stanford, ran a diabetes echo program extension for community health outcomes, where we used tele education sessions to educate GPS. And I was shocked at the huge number of type one patients, not so much the adults, but even kids in both of our states that weren't seeing an end. Chronologist regularly at all, and they were relying on their GP for pretty much all their their management. And none of these GPS had any comfort level at all with using a pump. Not a single one of them, right? It took a large lift just to get them to use a CGM. But, yeah, I think there is a space for a system that's, you know, doesn't require anything of the physician, other than entering a weight and getting comfortable with prescribing CGM, to consider improving control for those patients out there, because there's plenty of them. Yeah, so we've been working towards, you know that in in our echo sessions, and I think we will get to a point where we certainly have increased physicians out in the general community who aren't endocrinologist comfort level with, with using technology, and they're, they're sort of that pre contemplation phase, I think, with using pumps. And I think pumps like islet could certainly be a good opportunity for them.

Scott Benner 42:50
Is it? Is it ever get heavy for you? It does for me? Like, does it ever get heavy for you? That idea of, like, you know, the slow nature in which this all moves forward, that these tools exist and that you've got to talk someone into it, or worse, wait for a doctor to age out so that the next one comes in and that community and you can, you know what I mean?

Dr, Mile Haller 43:09
Yeah, many of my colleagues and staff will tell you, one of my traits is definitely not patients. So I'm probably the least patient when it comes to waiting for people to adopt things that the evidence prove work well, and yet we still see this, you know, this therapeutic inertia towards them. So it is frustrating, but it's also part of, like, you know, my passion project for helping improve the lives of people with type one by getting these tools out there. And so, like, you know, like, like, we're talking about, like, with inhaled insulin, I just think that it's, it's an inertia game, and we have to figure out how to win it by explaining it to people well, demonstrating the use cases for it, making sure there aren't other barriers in their way to use it. And then, you know that will happen, and whether that's inhaled insulin or pump use from general providers for the folks who aren't coming to endocrinologist, I think all those things need to happen and need to happen much faster.

Scott Benner 44:02
Yeah. Listen, I made a decision about 10 minutes ago that I'm going to take your recording and I'm going to make it part of the Grand Round series, because you're you're given a little Master's class here about how to think about taking care of people with type one diabetes. So I appreciate that. I'll say inhaled insulin, and so people understand what they're getting still, but this is part of a bigger conversation that I've been trying to have for a long time. There are just little dials to be turned, and things would be so much better for so many more people. I believe that doctors don't believe it half the time that it's even possible for people to to improve, but this making this podcast has shown me that there are many, many different ways to get information to people. A lot of people like to listen. A lot of people like to learn by talking to someone else online. They want to do something visual. You can't possibly know who all those people are. You can't know all the things they've been through before they get to you or how. All, you know, upbeat, they are depressed. Like, you know, I'm always fascinated, like, you'll talk to someone who just has the greatest attitude about everything, and they can't tell you why they have it. It's they've been like that their whole life, and they got diabetes, and they just carry that attitude right through diabetes. And there's the next person who, you know, it's a woe is me right away. You know, the world's been coming for me forever. This is just the next thing on the list. I can't beat this. I can't fight this. There are so many different psychological, social, financial impacts that people with type one have that like, I don't think that it benefits us to try to figure out each one. I think you just throw all the tools at them. You go, look like, here it is. Like, you go, find the part that helps you. And the way I've done that is by I have dumbed down diabetes into t shirt slogans, basically, like ideas that, like, I see somebody every day, tell somebody about a high blood sugar, go crush it and catch it. Like, that's me, Mike. I made that up. I made an episode where I said to somebody like, Don't stare at a high blood sugar. You have to get it down. Don't take three hours to mess with it, like, just just crush it and then be ready to catch it on the back end. And then we talked about how to do that. And now I see people all over the place doing that. I explained pre bolusing in a way that relates it to a tug of war that neither side is trying to win now, people, I see people all over the place go I finally understand Pre-Bolus like the way we talk about it from the doctor's office doesn't jive with most people.

Dr, Mile Haller 46:32
Yeah. I mean, you're clearly a gifted communicator, and being able to teach back things to people you know, like they're in kindergarten, is extremely effective. Your average physician is not, yeah, not, not, not, because you're kidding them, like they're not an intelligent person, just keeping it simple and making sure the message actually hits. You know, we often over complicate things to the point that patients don't use the skills we're trying to teach them how to use. So, yeah, I think it's, it's

Scott Benner 46:58
important. I often think, like, if you made me the lead salesperson at beta bionics, I'd sell a billion of those things. And I know exactly what to say to people. I know exactly how to make it attractive. I know what you got to go into the doctor's office say, look, go find me five of your worst cases. And like, watch over the next six months while we've improved their life. Go find me these people, and we'll show you how to use glps like that'll really help them, and then let the doctors go off and replicate that over and over again. The glps are fascinating to me. Really, the the amount of people are like, you know, Oh no, it's dangerous. I'm like, you know, you threw everyone on a GLP when you heard about it. And you've got some poor person here with type one for 35 years who's had an A, 1c, in the eights and the nines for 35 years. Then they had they had a digestive issue and a GLP. Like, well, no kidding. Like, right? Like, they probably have some version of gastroparesis to begin with. Then you slow down their digestion more with this drug. That doesn't mean everyone's going to have that problem. And I was feeling that when you were talking about the too, because what I'm thinking is is the healthier you you launch into this endeavor, the fewer problems you're likely to have along the way. Like, you know, if you just hand it to a guy who's been smoking cigarettes for 35 years, and his a one sees been in the eights for a while, like, well, he might cough. I get that. You know what I mean? Like, he's 50 pounds overweight, like, but I don't know. Like, I sometimes with these new things, the first thing people see is not usually the right answer, but it is the thing that sticks with them forever. Does that make sense?

Dr, Mile Haller 48:27
Yeah, I think most physicians and many families are risk averse, and so they're going to be extra tweaked to look for a bad outcome, and then, like you said, kind of focus on that even when it doesn't reflect the majority experience. I think there's always something to be learned from you know, when things don't go right, that doesn't mean that a drug or a modality isn't a really good option for many people. I personally love using GLP ones. And, you know, 30% of type one patients are obese in the OS. It doesn't, you know, doesn't get away from them just because they have type one Americans are are heavier than the rest of the world, and therefore they have more insulin resistance, and it makes it, you know, Snowball forward when they need to use more insulin. So I've had great success with using GLP ones as an adjunct for the right patient, just like I've had great success using inhale insulin for the right patient, you know, as an adjunct, and sometimes even as they're only rapid acting insulin, you know, I think we have to continue. It's why I like diabetes care. I think, you know, the field continues to evolve. We have all these tools, and figuring out which set of tools works best for the right patients, to me, is the fun of trying to, you know, figure out what works best for for people, and helps, helps more people get to that a 1c target and

Scott Benner 49:43
don't throw the baby out with the bath water. The first thing that you see isn't, you know, like, it's not a rule for everybody. So tell me something. What did this study show, and why are you so excited about it for the new population that it's now available

Dr, Mile Haller 49:56
for? Yeah, so the inhale one pediatric study. He randomized kids to either getting inhaled insulin for all their meals, corrections, all the rapid acting use, or they stayed on a basal insulin and did multiple daily injections, you know, with rapid acting injectable insulin. And after 26 weeks of being on whichever group, they were randomized to the the A, 1c at the end of the day was basically the same between the inhaled insulin group and the injected insulin group, and it was really well tolerated. Very few kids stopped using the inhaled insulin. There was actually only a small number of kids who reported having cough beyond the first couple weeks of use. So people definitely got got used to that and figured out how to mitigate that issue. You know, interestingly, there was increased perception of enjoying using the insulin that was inhaled versus the injected insulin, amongst both the parents and the kids who are actually using, you know, using the phrase. So I think at some point that is something that's important to keep in mind, that it made their perception of living with diabetes a little easier. And that's something that's really an important endpoint for folks, as we get more and more people to target, you know, the next thing is, well, how can I get to target with less burden? So I think that's important. And there was less, you know, weight gain in the in the group that was randomized to inhaled insulin. So that too, as we were just talking about, you know, it's a big problem with obesity and type one in our patients, and any therapy that can potentially reduce that risk somewhat is something that we should be considering as an option. So, yeah, I'm excited to see it move forward and get get that FDA

Scott Benner 51:33
approval. What's the reasoning behind the less weight gain? Do you think, I think it has to

Dr, Mile Haller 51:38
do with more physiologic dosing? You know, you're really talking about giving insulin much more, like insulin that would be coming out of your pancreas into the portal vein directly and deliver and so you don't have excess insulin being around that you then have to feed to avoid the low, post meal, post snack, you know, exercise related, so likely, that's the modality.

Scott Benner 51:57
That's it. And then what's this is with the FDA now? Or what's the process like?

Dr, Mile Haller 52:01
Yeah, the company has filed for approval with these data. It can be a six to nine month process to get all the way through, but with any luck, at the end of that timeline, they'll have the stamp of approval from the FDA and then be able to start marketing it and selling it to pediatric offices, and that means their sales force will be able to visit and provide samples. And I think you know that that will be one of the key things to getting over that therapeutic inertia, to have people have access right in their offices and say, Oh, look, here's the phrase. I Why don't we try it? And then I think you'll have many more patients and families who get to experience what we were talking about in the last hour, right? And say, Oh yeah, this, this really is a nice tool to have in my toolbox for those pesky highs, or for these particular meals or for this sports situation. And then it will get out there. And hopefully, you know, be part of the of the thought process when people start to enter a room and say, what's going to be best for the patient in front of me

Scott Benner 52:56
today, it just occurred to me, as you were saying that, like, great. This is the, this is maybe the most hopeful inroad to making people understand how well this works, because you're not going to, you don't change adults minds about anything, right? So you get people when they're younger and they can become accustomed to it, see how valuable it is for them. They'll carry they'll carry that into adulthood,

Dr, Mile Haller 53:16
exactly to that point. I'm really excited about a study that they're planning coming up, which is going to be offering inhaled insulin at diagnosis. So imagine, go back to when your daughter was diagnosed in the first thing they walked in the room and they said, we have this way of managing diabetes. You'll take this one injection a day, and then everything else will be inhaled, and you never were presented with the need or the option to give multiple daily injections or be on a pump, my hunch is that's going to play really well with a certain population of folks, and that they'll, you know, they'll learn from the very beginning that this is the paradigm for how we deliver insulin, and they'll see that they have great control, and they'll want to stay on it, versus trying to convince people to change what they're already doing when it's working pretty Well for most.

Scott Benner 53:59
Yeah, well, I hope that companies in general realize at some point that it's not just a sales person that you need. At that point, it's a person who understands it, you know, like somebody who can actually talk about it with the care and concern that you and I have, but doesn't feel salesy and doesn't feel like a doctor. Like, I know that's strange, but like, if somebody could sit down in that moment and go over those things with you, here are the options for how we do this. Here's the, you know, the pros and the cons. Yeah, then let people make a decision that fits best for them, and they'll be more successful once they've done that. And you'll get more people who will do what is considered like a different idea the way this is all set up. I know it's no one's fault. Like, I really understand that. Like, most people are not sick most of their lives, you're suddenly diagnosed with something. Your expectation of the way medicine works is that you go to the Magic Man and the magic man gives you a thing, and then you're better. Like, right? Like, that's really people's understanding. Standing of medicine. I broke my arm, and one day it's not broken anymore. I got sick. I took these 10 pills three times a day for 10 days, and when it was over, I wasn't sick anymore. You don't grow up with an expectation that you're going to be managing, you know, like, I've put it in the past, like, diabetes is like trying to remember to make your heart beat. It's like, if I put you in charge of, like, you know, breathing and I said, like, breathe in, breathe out. You had to say that to yourself every couple of seconds for the rest of your life. It feels like that. It's not the way people imagine their lives. They need to be set up for success very early on, when they are what I'm telling you, I see Mike, is that when you set them up for success early, they don't struggle as much, and they actually have that success when it's over. So I hope that we can all find a way to that. It's right there. The beta bionics thing is one arm of it. The inhalable is one arm of it. GOP is one arm of it. You just have to get the right message makers out there to let people know. I think so.

Dr, Mile Haller 55:56
You're again, very perceptive. The thing that ironically, made the biggest difference in outcomes in our echo programs was, was exactly as you described, peer coaching. Wasn't the docs were the last to be important in all this. Frankly, it wasn't sales reps. It wasn't the tools. It was having somebody who had lived shared experience, who could talk to people without, you know, bias and without judgment, and say, Oh, here's some other options you might consider. And boom, we saw people seeing marked improvements in their

Scott Benner 56:26
outcomes. Let me pitch my last idea with your mic as you go out the door. I think people's endo appointments for their type one diabetes should be in a group setting, not one on one.

Dr, Mile Haller 56:35
We have done just that. It's extremely effective. The only challenge is the US healthcare system and figuring out how to make it all billable. All billable. Yep, it's another reason camp is so great. Camp is like a one week long group education session, highly effective for everyone. I'm

Scott Benner 56:50
sure you can do the same thing, but I have a crisp one hour talk. I could give it to you, and you'll know how to take care of yourself when it's over. Yeah, and if you came back and build on that through Q and A's. Like, if the same group of 500 people showed up in an auditorium once every three months and build on their knowledge through Q and A's together a year later, they'd be done. They wouldn't even need you anymore. I see how the podcast works, and it could be replicated in real life. But like you said, like every time I bring it up to somebody, the next thing they say is, well, we don't know how to bill for that, and so

Dr, Mile Haller 57:22
somebody's got to break the system. Well, the system's broken. Somebody's got to come up with a better way to do it and deliver it. And I agree, there's, fortunately, there's a growing number of people who were setting up for success early on, like you described, who we've achieved that goal. They don't need us. They're doing great. We don't need to see those people every three months and make them come in for, you know, a check the box, visit. And we've, we've started to not do that as much in our clinic, so we can put more energy in the folks who really need it. But even those folks need need better ways of of getting them

Scott Benner 57:50
information. It's difficult because you don't build lifelong customers. I had to early on with the podcast tell myself, like, you know, my goal is for you not to listen to the podcast anymore, which is tough for me, because it's hard for me to keep it going then, but I found ways to keep it going. And, you know, other physicians could could as well. Like there's a way to put people out into the world healthy, in charge of themselves, where they're not going to see problems down the line nearly at the same rate. And right now, at best, we give people don't die advice. It's, you know, you're not gonna die, but you're not really gonna live well, and at least it's not on me. And that gets passed down the line, and then some poor doctor at the end of the line manages you out at the end of your life. And it just, it's a weird setup, like, I mean, we all know, like we're probably preaching to the choir here, but there's ways to accomplish this, so I appreciate you giving your opinions today and adding to the conversation. Thank you very much. It's been a pleasure being here. Awesome. Hold on one second for

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Scott Benner 9/22/25 Scott Benner 9/22/25

#1633 Bolus 4 - Pancakes

Jenny and Scott talk about bolusing for Pancakes.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends and welcome back to another episode of The Juicebox podcast.

In every episode of Bolus four, Jenny Smith and I are going to take a few minutes to talk through how to Bolus for a single item of food. Jenny and I are going to follow a little bit of a roadmap called meal bolt. Measure the meal, evaluate yourself. Add the base units, layer a correction. Build the Bolus shape, offset the timing. Look at the CGM tweak for next time. Having said that these episodes are going to be very conversational and not incredibly technical. We want you to hear how we think about it, but we also would like you to know that this is kind of the pathway we're considering while we're talking about it. So while you might not hear us say every letter of meal bolt in every episode, we will be thinking about it while we're talking. If you want to learn more, go to Juicebox podcast.com. Forward slash, meal, dash, bolt. But for now, we'll find out how to Bolus for today's subject. Please don't forget that nothing you hear on the Juicebox podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan or becoming bold with insulin.

A huge thanks to my longest sponsor, Omnipod. Check out the Omnipod five now with my link, omnipod.com/juicebox you may be eligible for a free starter kit, a free Omnipod five starter kit at my link, go check it out. Omnipod.com/juicebox Terms and Conditions apply. Full terms and conditions can be found at omnipod.com/juicebox Jenny, we are going to do pancakes. Oh, pancakes. Now we have two different pancakes sitting here. We have the ones for those of you who are in the grocery store buying the Betty Crocker Bisquick, shake and pour pancakes. And don't put your heads down. Stay proud. I know you'd buy them out there. Jenny, do you even know what this is? It's a plastic bottle that you pour water in and then you shake, shake, shake, shake, shake it up, and you have pancake mix when it's over. You don't know this. They

Jennifer Smith, CDE 2:25
didn't know that they made them that way. I thought you still had the powdery stuff that you had to mix in a real bowl at home. I did not

Scott Benner 2:32
know you can buy it like that too. This is, like, this is next level, I'm not gonna say lazy, but this is next level, easy, okay. Like, it's a plastic jug. You pour cold water and you shake it up, you have mix. I have tried to Bolus for them, and it ain't easy. So, like, I could do it, but it's not easy. It takes pre bolusing. It takes extended boluses. It takes increased basal over top of like eating and Arden does not use syrup with sugar in it. As a matter of fact, she oddly eats pancakes dry. Sometimes she won't even put butter on them. Sometimes. Now I have those. We're going to look at those. But then I also have a very simple to make on your own pancake recipe that has been on my blog for years that does not cause any consternation the way these the mixes do. But let us start with the mix nonetheless, and that's

Jennifer Smith, CDE 3:26
interesting. I would expect what I'd expect from both of them in the extended nature of insulin need after has is not the upfront, but it's the long term. Would be the because of the way that you cook them.

Scott Benner 3:41
Okay? Yeah, I'm not sure. I don't know why, but, like, all I know is simple ingredients that are real seem to be I'm not, listen, they're still pancakes. It's not like bolusing for you know

Jennifer Smith, CDE 3:53
what I would expect? Your recipe is real flour, right? It doesn't have all of the added preservatives. It

Scott Benner 4:01
doesn't. And I do spend a little extra money when I buy flour in the house. It's a little better, but it's still it's got butter. You'll see. You'll hear it when you hear it. But let's start with, let's, let me turn to a new, clean page on my shaking bottle. Let's start with the Benner cake. This quick shake and pour buttermilk pancake mix, 10.6 ounces a serving size is a this is hilarious. A half a cup of mix is a serving size, and they're calling that three pancakes.

Jennifer Smith, CDE 4:29
And is that dry mix before you've mixed it with the liquid ingredients, that's the next question.

Scott Benner 4:36
I think if it's three, I don't know, I don't know what they're saying. So let's look on the it's 10.6 ounces.

Jennifer Smith, CDE 4:44
That would be my consideration. It's that you've got a half a cup of dry mix, and what you add to it, liquid wise, it sounds like it's just water. You don't have to add milk or other nutrient containing foods. So if it's just water. So the whole container, I would expect, takes a certain amount. So if you break it down to a half a cup of the dry mix, how much water goes in? That probably makes three. Does it give a diameter? To

Scott Benner 5:13
be honest, I think it might mean the mix with the liquid in it. Oh, yeah, because it's saying there's five. I'm trying to think of, I have used this before, so five servings of a half a cup? Yeah, I bet you there's about two and a half cups of liquid in there. Yeah, I'm gonna go ahead and say that this means a half a cup of the actual mixed is there some tiny pancakes? Man? Well, that was my point. Is that this is where they're three pancakes. It's got to be like three inches Exactly. They got to be the tiniest goddamn pancakes you've ever seen in your life, is my point. So again, this is where they're going to mess you up, because no one's making a pancake that's two and a half inches across. No, no. So anyway, a grain of salt on the on the serving size. But let's just say, why don't we just say that you eat half of the container? That makes sense. Okay, so, so let's call it servings in the container. Yeah, there's five servings in the canner you're gonna have. Let's just say you're gonna have two of them. You're gonna have two servings. So this is six grams of fat. It is. Where are the car? Oh, it's 9090, carbs. 45 for a serving. 45 for a serving. So 90 for two servings, you get 90 carbs. You're getting six grams of fat, a lot of a lot of sodium, by the way, you're gonna see we're eight, almost 1000 milligrams of sodium. Wow, 480 per serving. Five or a gram for a serving. So two grams sugars, including nine grams of added sugars. You're getting, you're getting 10 grams of sugar in a serving. So 20 grams of sugar in that because there is at, I mean, most of it's added. Actually, they are adding a lot of sugar to it. Protein six, so you're getting 12 protein total. Okay, don't worry, there's calcium and iron in them. You're gonna live forever. The ingredients are enriched flour, bleached wheat flour, malted barley flour, niacin, iron, thiamin, mono nitrate, riboflavin, folic acid, sugar, Defatted soy flour. I don't know what that means. Leavening agents like baking sodium, sodium, sodium aluminum phosphate and mono calcium phosphate. There's also palm oil, dextrose, buttermilk, salt, something that's called da temp, but it's all in caps. That scares me, for some reason. I'm gonna look that up later. Contains wheat, soy and milk ingredients. Okay, well, let us go to our breakdown list. We have measured our meal. Our meal is 90 grams of carbs. We are one unit for 10. So that's going to be nine units of insulin. We're going to evaluate ourself again, this is the morning, I would have to say another evaluation here is, I mean, how many people are making pancakes and not putting bacon or some sort of, like a breakfast meat with it, which is, I know that's not what we're talking about right now, but like, you know, like, that's going to hold up the whole, the whole thing well,

Jennifer Smith, CDE 8:24
and I think in the realm of, again, your listening body, a lot of people are all actually trying to do that. They may not have before, but they may be trying to do that to mitigate the impact of what they expect the pancakes to do?

Scott Benner 8:41
Yeah, I'm saying the only the issue there is, like, you're trying to add protein with it. So in the morning, protein might mean bacon, and then bacon is going to mean fat, and then you're going to have, you know, you're going to get the lift from the fat later too, right? Okay, calculate our food. Bolus, we've done that. We have nine units. What do you think? Jenny, you want to you wake up in the morning, it's Saturday morning, you are having the experience that Arden has been having lately. A hot shower is shooting her blood sugar up. Never used to happen. All of a sudden, hot showers, boom, like she's

Jennifer Smith, CDE 9:12
going and it's not just her CGM that's being weird. It's actual, by finger six, she's rising too.

Scott Benner 9:17
She's jumping up in hot showers lately. Okay, so you get out of the shower, you come downstairs, Mom, it's Saturday. What are we doing? Oh, you're lucky. I'm a great parent. I've bought you a bottle of pancakes, and again, I've made them so you know, if there's shade, it's for everybody. There you go. And my blood sugar is 150 Oh, now I need a half a unit to move the blood sugar, probably more. Your blood

Jennifer Smith, CDE 9:40
sugar still rising according to the CGM trend, or is it stable at 150 let's

Scott Benner 9:44
call it stable, just to make those okay. Okay, so I need a correction for my one unit moves us 10 carbs. One unit moves us 100 points. That's for our examples. So now I'm looking at a nine and a half unit meal, uh, meal, Bolus. Do you. And what I hear from people all the time is like, oh, big Bolus to scare me. So I think that they can, often people look at them go, that's a lot like, you know, I don't know if I'm gonna put all that in there. I would say, you know, I think your rule of thumb here for double whatever you find works for you. So if you found, like Jenny used in other examples, if 12 minutes is a good Pre-Bolus for you, for something like this, you're going to need 25 minutes. This episode is brought to you by Omnipod. Would you ever buy a car without test driving it first? That's a big risk to take on a pretty large investment. You wouldn't do that, right? So why would you do it? When it comes to choosing an insulin pump, most pumps come with a four year lock in period through the DME channel, and you don't even get to try it first. But not Omnipod five. Omnipod five is available exclusively through the pharmacy, which means it doesn't come with a typical four year DME lock in period. Plus you can get started with a free 30 day trial to be sure it's the right choice for you or your family. My daughter has been wearing an Omnipod every day for 17 years. Are you ready to give Omnipod five a try? Request your free Starter Kit today at my link, omnipod.com/juicebox Terms and Conditions apply. Eligibility may vary. Full terms and conditions can be found at omnipod.com/juicebox find my link in the show notes of this podcast player, or at Juicebox podcast.com

Jennifer Smith, CDE 11:30
and the Bolus size really does scare you. A stepping stone to getting there, if you really love this product, would really be do that 25 minute Pre-Bolus with half of what the Bolus recommended is, if it's nine units, take four and a half. Take that with the Pre-Bolus, and then as soon as you start eating, take the other because we all know the insulin action time is not right here and now, as it's delivered, still takes a little build up time to get it working. So that's it's this strategy that, while it may not be beneficial for keeping your blood sugar under 180 at least you're getting the whole Bolus without as much fear. Is truly what's in the picture?

Scott Benner 12:13
Yeah, I'm gonna say, you know, just from a person who's, you know, raised a kid with type one diabetes, I like Carrie's sugar free syrup. Of all the ones that we've tried over the years, that one seems to taste the most like syrup carries, yeah, S, C, A, R, y, s, do you have one that you tell people about?

Jennifer Smith, CDE 12:31
You know, there are two that I think have quality flavor, which I've heard from a couple of people. They really don't like one of them, the LE conto brand. I don't have an issue with the flavor of it. The other one is the RX sugar. That one has a really nice maple sugar. It's all yellows, sort of non sugar alternative, kind of in it. So those tend to work well, I've never seen an issue with the RX sugar. I while there are, again, on all of these alternative sugars, carb counts on them, probably like the carries. I don't know if Arden has to count any of the carb grams on there, but I don't for the RX sugar. But I'm also not eating, like a half a cup of it.

Scott Benner 13:17
I don't see the carries doesn't add rocket fuel to pancakes for her. So okay, I take that as a way that she probably doesn't need to cover it. Now, listen, I happen to know because during covid, I went on an extensive research to find out why the waffles at a local diner were so good. I was really bored during covid, and I found out what syrup they were using. So I'm going to tell you that the one you get in a diner that you probably think of is tasting good has a serving size of two tablespoons, which no person in the history of the world has ever used on pancakes. But let's just say two tablespoons, not only are you going to get 100 calories from that, but you are going to get 26 grams of carbs from two tablespoons of this, if you're doing 90 grams worth of pancakes and a quarter of a cup of syrup, which I'm still being generous for people, but let's say that. Let's say it's, it's another 52 grams, yes, yes. It's another 52 grams of insulin of carbs, which is now putting your, I'm gonna have to do some math here. That's 142 but that is that 14 plus the correction, that's just about 15 units for that. Then if you're gonna put, yeah, Jenny's like, I haven't taken 15 years, and it's less than three days, that's not true, but not all at once. Oh, my God. My point is, is that you can't, you can't come online all the time and tell me I don't know how to Bolus for pancakes if you're not addressing them for what they really are, that's all like, you're gonna have to come at it for what it really is. You can't say, oh, that number seems too big, or I've never Bolus that much before, like this is what it is.

Jennifer Smith, CDE 14:53
And I think a valuable piece to point out too is, you know, you brought up a waffle house for. Waffle right? Let's say you have figured out your pancakes at home. You know the portion size. You know exactly what goes into them. When you go to your local pancake place, it will be different. Is it a little easier to swag the pancakes you're eating? Sure, because you have something that you've figured out to work, but also your pancakes at home might be four inches, and this pancake that comes out to you now is the whole, the whole plate, right? And so then you end up, let's say you swag it pretty good in terms of the grams of carb, but now in terms of worry about that amount of insulin, you put that in your pump and you're like, my gosh, 14 units of insulin. I usually take five for what I eat at home. Yeah, what you need is what you need, right? Based on how much you're eating and how much you're calculating. So as long as your insulin to carb ratio is the same, sure, you might use five units at home, but you may very well need the 14 units because of the difference in portion.

Scott Benner 16:04
I would say that, you know, when we talk about, you know, looking at your CGM down the line an hour, three hours, and evaluating what happened, so you can tweak it for next time. If that amount of insulin scares you to the point where you're like, I can't, I just can't do all that. Like, I don't, not understand. But then when you're doing your valuation, and you end up having to make a correction. Look at that insulin. Like, the amount that you use to correct with, is that the amount you skipped in the initial Bolus? Like, is it close? Like, that'll help you get to the idea of what you actually need. I'm not saying run out there and make some like, super aggressive Bolus. Like, you might be the person who doesn't need it. Like, you know, like, you're gonna have to work into this. But this is the thought process for going through this and and I'll just say here at the end, if you go to Juicebox podcast.com and type pancake into the search bar, you'll get a simple recipe that I use when I make pancakes home. It's a cup of flour. It's all purpose flour. It has two tablespoons of sugar in it, and it has two teaspoons of baking powder, a teaspoon of baking soda, a pinch of salt, a cup of milk, one large egg, two tablespoons of melted butter and some vanilla extract. And is it like drinking water and bolusing? It's not. It's still like pancakes, but it's not like the packaged pancakes, the box pancakes that were there. So

Jennifer Smith, CDE 17:21
what is your since you know and you have had both, what do you see is your difference in strategy, knowing that who you're feeding it that she's still going to eat the same amount of pancakes either way, right? She's

Scott Benner 17:37
tough, because she'll like, she'll grab them and then start eating. And they go, can I give me another one of those? And some days she's like, give me some syrup. Or someday she's like, I'm just gonna eat them dry. Like, see, it's a little bit the syrup sugar free. But what I like is I take a couple of different strategies and I throw them together nice long Pre-Bolus. It's gotta be 20 minutes at least, right? I like to see a falling blood sugar when the food hits. And then I put a basal over top of the first hour, at least, right? Like, because my goal is not to leave 90, right. Like, especially on stuff like this. Like, I'm more aggressive on the things that, like, could possibly lead you to an afternoon of 350 blood sugars, right? I don't mind missing on something that goes to 160 and we have to fix it, like, whatever, like, but I don't want to get I don't want it to ruin the day. So I would lay a basal, like an attempt basal, over top of the Bolus. And, you know, Arden's using trio right now the do it yourself. App, it's very simple to do. I'd put the Bolus in 20 minutes before, you know, if she had a lower, stable blood sugar going in, if she came downstairs out of that hot shower, and she was 170 and she said, I want pancakes. The next words that would come out of my mouth are Bolus, like, before I even go to look to see if we add an egg in the refrigerator now, like, just now, you know. And it's momentum, like Jenny, it's timing and amount. Like, I know this is fun to break down like this, but like, it's the right amount of insulin at the right time for the situation. So and then I like that you can bail on the temp basal if you start getting too low. And then to me the L or the look at the CGM in meal bolt. I keep watching. If I see a drift up, I'm right back on. I smack its hand like it's trying to shoplift. You know what I mean, like right back at it again.

Jennifer Smith, CDE 19:22
And with trio, you've probably like me, I've been using trio for a year now, and honestly, what I've found is it's less likely to need to do that back end slapping, mainly because it does a good job of that additive. Depending on how you have your dials turned in, it does a pretty good job of hitting for you before you have to step in, which is nice, because you can kind of step away for a bit right in

Scott Benner 19:50
the end. It's in the podcast somewhere. Jenny and I've talked about it. I've said it over and over again, but I leave a over heavy carb situations, I lay a blanket of insulin over top of it. Like a weighted blanket so it can't stand up and

Jennifer Smith, CDE 20:02
and in this case, I think that weighted blanket effect, so to speak, is relative to, as I pointed out initially, both types of pancakes require cooking them in oil

Scott Benner 20:15
or butter, or I do butter on the pan, and very little like, I actually butter the pan, and then I wipe it off like so I just don't want it to stick. That's all I care about. But I do see you're not wrong. I've seen people look like they're deep frying their pancakes. Yeah, that's a more southern thing, too. I've noticed when I'm traveling sometimes too. Is that maybe what could be?

Jennifer Smith, CDE 20:34
Yeah, could definitely be. I think it's also restaurant style is definitely heavily cooked in some type of oil or butter on the surface,

Scott Benner 20:45
they're trying to kill you, for sure. Yes, actually, I guess what they're trying to do is give you enough butter that you're like, I'm coming back there one day. Yes, yeah, okay, all right, this is good. That's, that's, that's

Jennifer Smith, CDE 20:57
that long term effect. You're not only thinking about carbs, but you're thinking about that lingering, yeah.

Scott Benner 21:02
So, I mean, I'm gonna tell you this all changes. You add bacon to this, or we're from the Northeast pork roll to this, and now, yeah, right. And now my checking, like, isn't just one, two hours later, because if I get pancakes right, two hours later, I'm done. It's good, but you add bacon or some fatty meat to it, now it's three, three and four hours later, like you still have to be looking Sure. So okay, all right, I appreciate it. Awesome. Thanks. Thank

you. A huge thanks to my longest sponsor, Omnipod. Check out the Omnipod five now with my link, omnipod.com/juicebox you may be eligible for a free starter kit, a free Omnipod five starter kit at my link, go check it out. Omnipod.com/juicebox Terms and Conditions apply. Full terms and conditions can be found at omnipod.com/juicebox

Unknown Speaker 22:00
you in

Scott Benner 22:04
each episode of The Bolus four series, Jenny Smith and I are going to pick one food and talk through the bolusing for that food. We hope you find it valuable. Generally speaking, we're going to follow a bit of a formula, the meal bolt formula, M, E, A, l, B, O, L, T. You can learn more about it at Juicebox podcast.com, forward, slash, meal, dash, bolt. But here's what it is. Step 1m. Measure the meal, E, evaluate yourself. A, add the base units, l, layer, a, correction, B, build the Bolus shape, O, offset the timing, l, look at the CGM and T, tweak for next time. In a nutshell, we measure our meal, total carbohydrates, protein, fat, consider the glycemic index and the glycemic load. And then we evaluate yourself. What's your current blood sugar, how much insulin is on board, and what kind of activity are you going to be involved in or not involved in? You have any stress hormones, illness, what's going on with you? Then a we add the base units, your carbs divided by insulin to carb ratio, just a simple Bolus l layer, a correction, right? Do you have to add or subtract insulin based on your current blood sugar? Build the Bolus shape? Are we going to give it all up front, 100% for a fast digesting meal, or is there going to be like a combo or a square wave Bolus? Does it have to be extended? I'll set the timing. This is about pre bolusing. Does it take a couple of minutes this meal, or maybe 20 minutes? Are we going to have to, again, consider combo square wave boluses and meals, figure out the timing of that meal and then l look at the CGM an hour later, was there a fast spike? Three hours later, was there a delayed rise? Five hours later, is there any lingering effect from fat and protein? Tweak, tweak for next time. T What did you eat? How much insulin and when? What did your blood sugar curve look like? What would you do next time? This is what we're going to talk about in every episode of Bolus. For measure the meal, evaluate yourself, add the base units, layer a correction, build the Bolus shape, offset the timing, look at the CGM tweak for next time. But it's not going to be that confusing, and we're not going to ask you to remember all of that stuff, but that's the pathway that Jenny and I are going to use to speak about each Bolus. I can't thank you enough for listening. Please make sure you're subscribed or following in your audio app. I'll be back tomorrow with another episode of The Juicebox podcast. The episode you just heard was professionally edited by wrong way recording, wrong wayrecording.com.

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Scott Benner 9/19/25 Scott Benner 9/19/25

#1632 Bolus 4 - Cinnamon Toast Crunch

Jenny and Scott talk about bolusing for CTC.

+ Click for EPISODE TRANSCRIPT

Scott Benner 0:00
Hello friends and welcome back to another episode of The Juicebox podcast.

In every episode of Bolus four, Jenny Smith and I are going to take a few minutes to talk through how to Bolus for a single item of food. Jenny and I are going to follow a little bit of a road map called meal bolt. Measure the meal, evaluate yourself. Add the base units, layer a correction. Build the Bolus shape, offset the timing. Look at the CGM tweak for next time. Having said that these episodes are going to be very conversational and not incredibly technical. We want you to hear how we think about it, but we also would like you to know that this is kind of the pathway we're considering while we're talking about it. So while you might not hear us say every letter of meal bolt in every episode, we will be thinking about it while we're talking. If you want to learn more, go to Juicebox podcast.com. Forward slash, meal, dash, bolt. But for now, we'll find out how to Bolus for today's subject. Please don't forget that nothing you hear on the Juicebox podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your healthcare plan, or becoming bold with insulin.

Summertime is right around the corner, and Omnipod five is the only tube free automated insulin delivery system in the United States, because it's tube free, it's also waterproof, and it goes wherever you go. Learn more at my link, omnipod.com/juicebox That's right. Omnipod is sponsoring this episode of the podcast, and at my link, you can get a free starter kit. Terms and Conditions apply. Eligibility may vary. Full terms and conditions can be found at omnipod.com/juicebox Jenny, I have a list in front of me here that says this is the top 10 Best Selling cereals by boxes sold. Okay, be a lot of words here. You don't know Cheerios, Frosted Flakes, Honey Nut Cheerios, Honey Bunches of Oats, cinnamon toast, crunch, Fruit Loops, Lucky Charms, frosted Mini Wheats, life and my favorite from when I was a child, Fruity Pebbles. Now,

Unknown Speaker 2:29
you know a fruity pebble? I know what they look like. Yes,

Scott Benner 2:32
they're nothing like those bastardized Cocoa Pebbles, which are just garbage. I don't even know. I've never had them. Are they the same maker? One's chocolate and one's fruit. I bet you it's not chocolate or fruit, by the way. I just want to say

Jennifer Smith, CDE 2:47
that I'm quite sure not. So

Scott Benner 2:49
let's pick one of these, and Bolus for it. You want to go, Okay, how about Cinnamon Toast Crunch? Oh my gosh, sure. Sure. You think it has cinnamon in it. It might, hold on a second. It might toast. I'm

Jennifer Smith, CDE 3:02
sure that it has cinnamon, either that or the side of it says cinnamon flavoring. Well,

Scott Benner 3:08
you can get a mega box of it for $6.21 what a deal. Let's see here, Cinnamon Toast Crunch. I am looking at its label. All right, Jenny, let's see. What

Jennifer Smith, CDE 3:26
is this? Serving size, three quarters of a cup.

Scott Benner 3:28
Oh, interesting. The serving size is one cup. Oh, one cup. Actually, I got thrown off a little bit because this label is in English and Spanish, and I kept going like, this doesn't seem like a word, I know. Sorry. So it's one cup total carbohydrates, 33 what is 33 like the magic number, or something like that? 33 grams of carbs, dietary fiber. Three grams. People are gonna be like, are you subtracting the are you not subtracting fiber? Yeah, right. No, you don't subtract by total sugar 12. This is exactly the same as, like we did. How is that? That's crazy. But this isn't gonna hit like the oats. This is gonna hit like a truck. So also milk, right? So we have to, like, a cup of milk. We're gonna have to do a cup of milk on this, do a standard one cup of milk. Okay, hold on a second. And now, is there anybody that only eats a cup of cereal? That's the question. Just made Jenny,

Jennifer Smith, CDE 4:32
I'm just referring back to the big the big vats on the wall in a cafeteria at college that like it's got the poor nozzle that you just pull it down it cranks it all out into your bowl. And I remember watching people fill their bowls at school with, like, the Jethro bowl of cereal.

Scott Benner 4:55
What's the Jethro bowl? What did you just say? Gigantic, gigantic. Okay.

Speaker 1 4:59
Oh. Whole bowl. Really, it was probably half of a box of cereal

Jennifer Smith, CDE 5:03
in a bowl, as though they'd sit down

Scott Benner 5:05
to eat. Hold on a second, food. Label, milk, whole milk. What do you drink? Oh, we don't drink milk. Sorry, I'm just gonna

Jennifer Smith, CDE 5:18
the dairy industry is gonna be like, Damn, that girl, she doesn't drink

Scott Benner 5:21
milk, cup of whole milk. It was hilarious. 12 carbs and no fiber, 12 grams of sugar, sugar and milk. Why is everything 12? Oh,

Jennifer Smith, CDE 5:37
1212, grams. That's because the carbohydrate is the same as the sugars,

Scott Benner 5:41
right? Yeah, but it's not, like, added, right? They're not added, no. That's all just protect me. I was like, they're not adding sugar to milk. Are they?

Jennifer Smith, CDE 5:48
Nope, milk sugar, essentially, it's in there naturally, yep. All

Scott Benner 5:52
right, I'll accept that. So we have now we got to figure out what an actual serving size is. I mean, it's, I bet she's three cups. I would say the

Jennifer Smith, CDE 6:03
majority of people eat two cups, two okay, let's, I would say two cups. So it is. And I'm, I'm thinking, kiddos,

Scott Benner 6:11
okay, right? I think that's the biggest problem is that people just look on the back like, Oh, it's 33 carbs, and then they just fill the bowl up with it. And, right,

Jennifer Smith, CDE 6:19
yeah. So what's, Yep, exactly. So what's the first step? Measure?

Scott Benner 6:23
Yes. So first step M measure. So we're going to measure and say we're having two cups, which is now 66 carbs. And does that mean we end up with two cups of milk? Or you think it's still one cup? I would still say one cup of milk. All right, we'll be generous and say one cup of milk. 66 carbs from the Cinnamon Toast Crunch and 12 from the milk is 78 total carbs. Okay, now we're gonna evaluate ourselves, right again? Yes, it's morning time. Are you a person who has wait? I wonder how many people are gonna realize they do or don't have trouble bolusing in the morning. That it's more about the food and the lack of Pre-Bolus than their scenario. But you want to check your blood sugar. If you have a CGM. Take a look at it. If you don't, please check with the meter. Do you have any insulin on board? What kind of a day is this going to be? Is it going to be a stressful day? Is going to be an active day that might impact how you Bolus? Probably not for Cinnamon Toast Crunch, however. So we're going to calculate our food. Bolus, Jenny, we have 78 carbs. And you guys, I wish this is not. This should just be video so you can just see Jenny going like, you know, in a day? Is that a week? I don't understand, but 78 carbs. And so that's 7.8 units of insulin using our standardized one to 10 carb ratio, which we're doing for all of our examples. So now we have 7.8 units of insulin that we need. I mean, let's say the kids wakes up at 130 I think you'd a lot of you'd be thrilled if your kid woke up 130 right? But we're also one unit moves you 100 points. So let's add another unit, another point three to it. Let's just call it eight for fun. Now we got to take a look at what we're going to do. We're going to build this Bolus up like, what are we going to do with it? Pre-Bolus, four in the morning. Jenny, when do you put it? I'm sure I've written blogs about it. I'm sure I've talked about on the podcast that you know. Arden, actually, after it, we left an end to appointment one day, asked me back when we just didn't know what we were doing and everything was upside down, or a 1c was in, like, the mid eights. Is there anything I can do to help you with this? Like a little kid standing in a parking lot said to me, and I said, you could stop eating cereal for a little while till I can figure this out. Yeah, but I did get back to it, and you know, she doesn't eat cereal anymore, but I did figure out a Bolus for it, and I'm gonna tell you that the answer is an aggressive Pre-Bolus, an aggressive amount of insulin, and you need momentum on your side when that cereal kicks like there has to be such a pull from that insulin when that cereal kicks that you can keep your stability. I mean, I don't know, what do you think for you're gonna say a half an hour, right? Today's episode is brought to you by Omnipod. It might sound crazy to say, but Summertime is right around the corner. That means more swimming, sports activities, vacations. And you know what's a great feeling, being able to stay connected to automated in some delivery while doing it all. Omnipod five is the only tube free automated insulin delivery system in the US. And because it's tube free and waterproof, it goes everywhere you do in the pool, in the ocean or on the soccer field. Unlike traditional insulin pumps, you never have to disconnect from Omnipod five for daily activities, which means you never have to take a break from automated insulin delivery ready to go tube free. Request your free Omnipod five starter kit today@omnipod.com slash. Juicebox Terms and Conditions apply. Eligibility may vary. Full terms and conditions can be found at omnipod.com/juicebox type that link into your browser, or go to Juicebox podcast.com and click on the image of Omnipod right at the bottom. There's also a link right in the show notes of your podcast player.

Jennifer Smith, CDE 10:19
Well, one thing I would say is, if you have an idea of what you've mastered with another type of meal that isn't cereal, yeah, this is 12 minutes, yeah, let's say you've mastered something that you love to eat is 12 minutes. It has a different hit than cereal does for high glycemic like this, my strategy is double that as a starting place.

Scott Benner 10:47
Okay? So if right, 12 works for you, for most things, you're going to 24 minutes, yeah, or

Jennifer Smith, CDE 10:52
25 to round it out, just make it nice and even say, okay, 25 minutes. This is a hard hitting now we've doubled the the serving size on the package, right? It's not just one cup. We're eating two cups of it, and we're now eating 24 grams of added sugar. You know, how many teaspoons of sugar that is? Do you

Scott Benner 11:13
know 24 grams of sugar is, how many teaspoons of sugar?

Jennifer Smith, CDE 11:17
Yeah, how many grams of carb is in one teaspoon?

Scott Benner 11:22
Ah, did I stump? Scott, look, I know. Is it two? No, a teaspoon, like a level, a teaspoon, like a measuring teaspoon, four. Wait, there's four carbs in a measuring teaspoon of sugar. So not like the teaspoon that you use to put in your coffee, which is probably five teaspoons. So what does that mean? Put that contextualize that for

Jennifer Smith, CDE 11:43
Yeah. So now we have 12 grams in a cup. We're eating two cups of the cereal. That's 24 grams of sugar. 24 divided by four is how many teaspoons.

Scott Benner 11:53
Six. There you go. Wow, really? So I,

Jennifer Smith, CDE 11:59
and I bring this in not this is, again, this is not a judgment. This is a teaching piece, but it's teaching in the fact of we're considering the glycemic impact of this food. We're not just eating one serving now we're eating two, so you're increasing the load effect of a high glycemic food.

Scott Benner 12:16
Yeah. Also, let me read the ingredients for you from Cinnamon Toast Crunch, whole grain wheat, sugar. Also, I don't know if people know this, the order they're in is their amounts. So there's, it's mostly whole grain wheat. It is second, mostly sugar. Third, rice flour, canola and or sunflower oil. Can they not make up their minds? What does end or mean? So whatever they got laying around, it's whatever they it's a mix. There you go. What do we got today? Throw it in there. 1234, we are now five things deep. The next item that is most prevalent in Cinnamon Toast Crunch is fructose, then maltodextrin, dextrose, which I think sounds like another way to say sugar it is. We've just said sugar three times in a row, right? Sugar, fructose, dextrose, sugar, sugar, sugar, am I? Am I right about that 100% okay, all right. Salt, wow, cinnamon. We got the cinnamon pretty early. Oh, and it's not cinnamon flavor. It's real salt. It's real cinnamon. It's probably in there to mask whatever tri sodium phosphate is, soy, less is thin, less than, less than caramel color, Rosemary extract. Oh, a little the nature. BH, two added to preserve freshness. Vitamins and minerals, calcium carbonate, vitamin C, iron, zinc, they list them all here, A, B,

Jennifer Smith, CDE 13:37
what are? What are those? Therefore they're enriched or fortified, right? Enriched or fortified because all of that whole grain weed at the first ingredient that's been stripped, yeah, of all the beneficial vitamins,

Scott Benner 13:50
right? Oddly enough, like percentage of your daily value for the vitamins, it's between 10 and 20% for all those. So, yes, yeah, they've given you a vitamin in there. You could have took it on your own, though, we're gonna Pre-Bolus this meal. You know, double of what you find to be working with a food item that you're good at bolusing for. Again, I'll tell you, like on something this aggressively glycemic. I mean, there's a load here and an impact, right? The load from the processed food, the impact from the sugar. I think if you Bolus for this even super aggressively, and you're on an algorithm, and that algorithm is going to go, here's the insulin, if you I don't like this word, but if you mess up that Pre-Bolus and don't get the insulin ahead of the spike that's coming, that algorithm is going to sit for hours and not give you basal. There's no way you're not going to be 400 if you mess up the pre vault. Potentially, yeah, no way. There's a way. But like, yeah, potentially, and at least on a regular pump, your basal still churning, and might get in the way of it a little bit. So now, if this all works, I. Know this is going to sound crazy to people. Wait, somebody online is going to call me a insulin pusher. I can keep a steady line. Yes, with with cereal, it's a lot of insulin and a lot of timing, and you can do it. Would I do this every day? Even if I could? I would not. I'm just being honest with you. I've seen my daughter eat a bowl of cereal once in the last year and a half so, and I she was sick, and she's like, You know what I want? And I was like, What do you want? Just like, and she says, yeah. Like, I was like, all right, but could I do it? I could. I don't think it's the greatest decision you're ever gonna make in your life. But if this is your sitch, what am I 10? If this is your situation, I want you to Bolus, well for the cereal that's all like, I mean, you're gonna, I just don't want you having high blood sugars, which, by the way, are gonna, at some point, those big spikes are gonna turn to, like, a crashing low at some point in the future, too.

Jennifer Smith, CDE 15:51
So good if you don't figure out your strategy. And that's where the end of our acronym, your acronym, right? It comes in. It's evaluate. Watch that one hour, three hours, five hours. How did this meal filter out for you? What do you have to tweak for next time? And I, you know, I'd go back to a friend of mine, who I've known had for a long, long time. She also has type one almost as long as I do, and I don't know that she still does it. But years ago, before all of the aid assisted types of systems on the market. She wanted cereal once a year for her birthday. Yeah, that's what she wanted. And she did. She didn't have your acronym, but she figured it out. She tested it out, and what she found works. This is not medical advice, not encouraging you to do this.

Scott Benner 16:42
None of this is medical advice. I've been doing this for a long time.

Jennifer Smith, CDE 16:46
Was it was a timing thing. So she had to get the initial step of insulin added the right way. And what she found worked was doubling the dose of insulin that she would normally take for cereal, and on the back end, she suspended her pump. Okay, so at the Bolus time, she suspended her pump for hours after and over Bolus, the hell out of the cereal. Over Bolus up front to get ahead of getting too high. And on the back end, she balanced it out because she took away the basal, which is a slower drip, drip, drip, and she could take it away easily. So that

Scott Benner 17:26
might work on an A I D as well. It could potentially, yeah, what people have to understand about the algorithms, like at a basic level, is you tell it, these are your settings, and this is how much I ate. It believes you right? It is not going to adjust, because your blood sugar, like, shot up out of nowhere. It goes, no, no. They told us how much we did and we did the right amount, like, we're going to keep doing the thing we're doing now. Some of them will, you know, start pushing back as something rises and rises, but that pushback is not going to be aggressive enough to overcome a major Miss in the amount of insulin or the amount of timing that you choose. Okay, all right, like, I know it's not food you ate, but do you think you could sit down right now eat two cups of Cinnamon Toast Crunch and Bolus for it? Yes, yes. If I get you to do that on video one day,

Jennifer Smith, CDE 18:14
that'd be do it. I could do it. I probably wouldn't pick Cinnamon Toast Crunch, but something else that I'd

Scott Benner 18:20
prefer I take my hall pass on that one. All right, I appreciate it. We covered it, right? We're

Jennifer Smith, CDE 18:27
good. No, it's great, perfect. Thank you.

Scott Benner 18:37
Summertime is right around the corner, and Omnipod five is the only tube free automated insulin delivery system in the United States, because it's tube free, it's also waterproof, and it goes wherever you go. Learn more at my link, omnipod.com/juicebox, that's right. Omnipod is sponsoring this episode of the podcast, and at my link, you can get a free starter kit. Terms and Conditions apply. Eligibility may vary. Full terms and conditions can be found at omnipod.com/juicebox, hey, thanks for listening all the way to the end. I really appreciate your loyalty and listenership. Thank you so much for listening. I'll be back very soon with another episode of The Juicebox podcast in each episode of The Bolus four series, Jenny Smith and I are going to pick one food and talk through the bolusing for that food. We hope you find it valuable. Generally speaking, we're going to follow a bit of a formula, the meal bolt formula, M, E, A, l, B, O, L, T. You can learn more about it at Juicebox podcast.com, forward, slash, meal, dash, bolt. But here's what it is. Step 1m, measure the meal. E, evaluate yourself. A, add the base units, l, layer. A, correct. Direction, B, build the Bolus shape. O, offset the timing, l, look at the CGM and T, tweak for next time. In a nutshell, we measure our meal, total carbohydrates, protein, fat, consider the glycemic index and the glycemic load, and then we evaluate yourself. What's your current blood sugar, how much insulin is on board, and what kind of activity are you going to be involved in or not involved in? You have any stress hormones, illness, what's going on with you? Then a we add the base units, your carbs divided by insulin to carb ratio, just a simple Bolus l layer, a correction, right? Do you have to add or subtract insulin based on your current blood sugar? Build the Bolus shape. Are we going to give it all up front, 100% for a fast digesting meal, or is there going to be like a combo or a square wave Bolus? Does it have to be extended? I'll set the timing. This is about pre bolusing. Does it take a couple of minutes this meal, or maybe 20 minutes? Are we going to have to again, consider combo square wave boluses and meals, figure out the timing of that meal and then l look at the CGM an hour later, was there a fast spike? Three hours later? Was there a delayed rise? Five hours later, is there any lingering effect from fat and protein. Tweak, tweak for next time. T What did you eat? How much insulin and when? What did your blood sugar curve look like? What would you do next time? This is what we're going to talk about in every episode of Bolus. For measure the meal, evaluate yourself, add the base units, layer a correction, build the Bolus shape, offset the timing, look at the CGM tweak for next time. But it's not going to be that confusing, and we're not going to ask you to remember all of that stuff, but that's the pathway that Jenny and I are going to use to speak about each Bolus. The episode you just heard was professionally edited by wrong way recording, wrong wayrecording.com.

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