Juicebox Podcast: Type 1 Diabetes

Episode #1634 Grand Rounds: Inhaled Insulin
Host: Scott Benner
Guest: Dr. Mike Haller, Chief of Pediatric Endocrinology, University of Florida
Date: September 22, 2025

Overview

This episode of the Juicebox Podcast explores the evolving landscape of Type 1 diabetes management, with a focus on inhaled insulin (Afrezza), its integration into pediatric care, and the broader theme of empowering patients with innovative tools and education. Host Scott Benner and Dr. Mike Haller dig deep into clinical experiences, barriers to newer therapies, patient education, and the importance of individualized care. The discussion is lively, compassionate, and packed with actionable insights for patients, families, and healthcare providers alike.

Key Discussion Points & Insights

Dr. Mike Haller’s Background & Inspiration

• Dr. Haller shares his personal journey in medicine, inspired by his grandfather’s experience with Type 1 diabetes and his transformative time at diabetes camp.
  • “The 24/7 experience there is what really did it for me. Just seeing what living with type one is really like.” (03:34, Dr. Haller)
• Emphasizes the power of diabetes camps not only as community support but also as a recruiting tool for pediatric endocrinology.
  • “I require anybody who wants to come shadow with me to volunteer at camp...that experience tends to be so transformational.” (04:26, Dr. Haller)

Patient & Provider Expectations at Diagnosis

• Discussion on what families wish for at diagnosis vs. reality.
• The importance of acknowledging the wide range of patient backgrounds at diagnosis.
  • “Physicians need to do a better job of recognizing that there are big differences…The heterogeneity of presentation is becoming even more broad.” (07:53, Dr. Haller)
• The doctor’s role as “coach” and setting expectations for patient self-management.
  • “You, at the end of the day, are the player on the field...Our job is to give you the skillset to do that as well as humanly possible.” (09:26, Dr. Haller)

The Value of Community, Peer Learning, and the Podcast Medium

• Both speakers highlight the massive impact of peer-led and digital resources for patients outside clinical walls.
• The limitation of brief medical appointments vs. ongoing self-management.
  • “Patients spend less than 30 seconds on a 24 hour clock of their diabetes time with their provider.” (15:34, Dr. Haller’s paraphrase of Aaron Kowalski)
• Dr. Haller actively listens to patient needs through social media and community groups.

Introducing Inhaled Insulin: The INHALE1 Study and Clinical Realities

[18:38] – Main Inhaled Insulin Discussion Begins

What Is Inhaled Insulin?

• Inhaled insulin (Afrezza) offers ultra-rapid action compared to injected insulins.
  • “It is the fastest acting insulin we have objectively by quite a bit...” (24:54, Dr. Haller)

Barriers to Adoption

• Off-label status in pediatrics (currently FDA-approved only in adults), insurance hurdles, physician comfort, and therapeutic inertia.
  • “Getting people to do something new is always hard. This idea of therapeutic inertia is a very real thing in medicine.” (18:38, Dr. Haller)
• Historically, failures of earlier inhaled insulins have contributed to slow adoption.

Potential Uses: The Toolbox Mentality

• Inhaled insulin as a key option for rapid correction of high blood sugars, post-meal spikes, and in sports/active scenarios.
  • “If you just had it with you for those high blood sugars...it might be a significant reduction in stress and time spent dealing with diabetes.” (17:05, Scott Benner)
• Not meant to replace injected insulin for everyone, but its advantages shine in targeted situations.

Dosing Challenges

• Dosing is less intuitive—Afrezza cartridges come in fixed units (4, 8, 12) which do not equate 1:1 to injectable units.
• New patients need to “reframe” how they think about insulin dosing.
  • “Nobody wants to suddenly take three times more insulin than they’re used to…it's just the way the units are counted.” (30:29, Dr. Haller)

Clinical Advantages

• Ultra-fast onset, shorter duration minimizes hypoglycemia risk post-meal and during exercise.
  • “You can send your young athletes out on the field with a normal blood glucose...not worrying their lunch injection…is going to keep pushing them further [low].” (29:09, Dr. Haller)
• Use case: Exercise, correcting stubborn highs, high-carb meals (e.g., pizza/chinese), and potentially as primary mealtime/correction insulin.
• Ideal for proactive, CGM-using patients who can “sugar surf.”

Compatibility With Technology

• Potential synergy with AID (Automated Insulin Delivery) systems and pumps, especially as meal announcements.
  • “If you had a Bluetooth enabled inhalation device...algorithms would be able to do the rest.” (34:47, Dr. Haller)

Mental and Physical Burden

• Reduces time-in-range anxiety, can lower the cognitive and practical load of diabetes management.

The INHALE1 Pediatric Study—Findings and Hopes

[49:57] – Study Results

• Study randomized kids to standard MDI vs. inhaled insulin for all rapid-acting needs.

• Results:

  • Inhaled insulin proved “non-inferior” to injected insulin for A1C outcomes.
  • Better patient satisfaction, lower weight gain, and fewer persistent cough issues than anticipated.
  • “There was increased perception of enjoying using the insulin that was inhaled...amongst both parents and kids.” (49:57, Dr. Haller)
  • Lower weight gain thought to be due to “more physiologic dosing” and less need to overtreat post-meal insulin “tail.” (51:37, Dr. Haller)

• Regulatory Status:

  • FDA pediatric approval is pending, likely within 6-9 months from episode date.
  • Wider adoption expected once available, with the potential for samples in pediatric offices, and streamlined insurance coverage.

Real-World, Systemic, and Psychological Barriers

• US insurance system and FDA status major adoption blockers—especially for pediatric care.
• Therapeutic inertia: Slow adoption among providers due to comfort with current regimens and risk aversion.
  • “Therapeutic inertia is a very real thing... we have to figure out how to win it by explaining [the benefits] to people.” (43:09, Dr. Haller)
• Simplicity of AID systems vs. “tinkering” required for inhaled insulin seen as a barrier for some.
• Safety: Repeated studies show inhaled insulin safe, except those with significant lung disease or smoking history.
• Mental/structural barriers: Perceived risks, unfamiliarity, and a lack of robust peer coaching or group education opportunities.

Expanding the Care Paradigm

• Importance of adapting care approaches for different populations:
  • Those “struggling so hard” (A1C >9; about 20% in UF’s clinic population), who need more intensive, practical solutions and tools. (40:43, Dr. Haller)
  • The value of technology like the iLet “bionic pancreas” for patients not seeing endocrinologists, often managed by GPs with little technology training.
• Dr. Haller’s passion project: Overcoming inertia by peer coaching and strategic group education, such as the ECHO program with Stanford, and the potential for group appointment models.
  • “Peer coaching wasn’t the docs...it was having somebody who had lived shared experience…we saw people seeing marked improvements in their outcomes.” (55:56, Dr. Haller)

Memorable Quotes & Moments

• On Patient Empowerment:
  • “You, at the end of the day, are the player on the field...Our job is to give you the skillset to do that as well as humanly possible.” (09:26, Dr. Haller)
• On Clinical Relationships:
  • “If we aren’t putting young adults out into the world who can do all this really well without anybody’s help…we haven’t done our job well.” (09:55, Dr. Haller)
• On Innovation in Diabetes Care:
  • “Injected insulin has such a stranglehold on the psyche…people still choose the VHS tape to your point.” (28:32, Dr. Haller)
• On Inhaled Insulin as a Game-Changer:
  • “It is the fastest acting insulin we have, objectively, by quite a bit.” (24:54, Dr. Haller)
• On Group Education:
  • “Camp is like a one week long group education session. Highly effective for everyone.” (56:50, Dr. Haller)

Timestamps for Important Segments

| Timestamp | Topic | |-----------|----------------------------------------------| | 02:29 | Dr. Haller’s introduction and career path | | 07:53 | What doctors/patients wish for at diagnosis | | 15:34 | “30 seconds a day” provider-patient analogy | | 17:05 | The value of the community’s voice | | 18:38 | Inhaled insulin: what it is, study rationale | | 24:54 | Systemic and provider barriers to adoption | | 29:09 | Advantages of inhaled insulin and sports use | | 30:29 | Dosing paradigm challenges | | 34:47 | Tech integration and future potential | | 37:59 | DIY algorithms and inhaled insulin synergy | | 40:43 | Populations struggling with glycemic control | | 49:57 | INHALE1 pediatric study results | | 52:02 | FDA process and future accessibility | | 53:17 | Importance of early exposure in care models | | 55:56 | Peer coaching and real-world insight | | 56:26 | Group appointments and systemic barriers |

Episode Tone & Takeaways

• Tone: The episode is candid, hopeful, pragmatic, and deeply empathetic. Both Scott and Dr. Haller speak in plain language but don’t avoid medical complexity when needed.
• Key Takeaways:
  • Inhaled insulin is a promising and underutilized tool, especially for specific patient use cases and scenarios.
  • Systemic and psychological barriers—sometimes more than scientific limitations—impede wider use of effective diabetes treatments.
  • Success in diabetes care is best achieved through individualized education, leveraging peer communities, and using all available tools wisely and flexibly.
  • Ongoing advocacy, provider education, and patient empowerment are needed to drive innovation forward.

Notable Quotes with Attribution & Timestamps

• “The 24/7 experience there is what really did it for me...being with these kids, doing all the things that you do at camp…And that experience was definitely transformative for me.”
  — Dr. Mike Haller (03:34)
• “Patients spend less than 30 seconds on a 24-hour clock of their diabetes time with their provider.”
  — Dr. Mike Haller (15:34)
• “It is the fastest acting insulin we have objectively by quite a bit because of you inhaling this bio-material technosphere…”
  — Dr. Mike Haller (24:54)
• “Therapeutic inertia is a very real thing in medicine.”
  — Dr. Mike Haller (18:38)
• “Peer coaching…was the thing that ironically made the biggest difference in outcomes in our Echo programs.”
  — Dr. Mike Haller (55:56)
• “You have to get the right message makers out there to let people know, I think so.”
  — Scott Benner (55:46)

Final Thoughts

Dr. Haller and Scott Benner provide a masterclass in forward-thinking diabetes care: they weigh new therapies honestly, share “real world” patient perspectives, and refuse to accept the status quo when better outcomes are possible. The coming approval of inhaled insulin for pediatric use marks a milestone, but the heart of this episode is the drive to meet patients where they are, expand the toolbox, and make sure every person with Type 1 has both the practical and psychological setup to succeed.