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Scott Benner 0:00
Have you ever wondered about inhalable insulin? Well, Paul's here today. He's a nurse, diabetes educator, a type one and an a fressa user. We're going to talk all about it.

Here we are back together again, friends for another episode of The Juicebox Podcast. Nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. Don't forget, if you use my link drink ag one.com/juice box, you'll get a free year supply of vitamin D and five free travel packs with your first order. And if you go to cozy earth.com and use the offer code juice box to check out, you're going to save 30% off of your entire order. Are you starting to see patterns, but you can't quite make sense of them? You're like, Oh, if I Bolus here, this happens, but I don't know what to do. Should I put in a little less, a little more? If you're starting to have those thoughts, if you're starting to think this isn't going the way the doctor said it would. I think I see something here, but I can't be sure. Once you're having those thoughts, you're ready for the diabetes Pro Tip series from the Juicebox Podcast. It begins at Episode 1000 you can also find it at Juicebox podcast.com up in the menu, and you can find a list in the private Facebook group, just check right under the featured tab at the top, it'll show you lists of a ton of stuff, including the Pro Tip series, which runs from episode 1000 to 1025 this episode of The Juicebox Podcast is sponsored by us Med, usmed.com/juice box, or call 888-721-1514, get your supplies the same way we do from us. Med, 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

Paul Hanson, RN, BSN, CDE 2:05
Hey, Scott. This is Paul Hanson. I'm a nurse diabetes educator. Was diagnosed with type one diabetes in January 2 of 1977 so you know, do the math. I'm coming up on 53 years. What is the math? 48 years? Good lord, I should check my blood sugar, huh? Pun intended. Honestly, I've been a supporter and follower of you and your daughter for quite some time, so really looking forward to the opportunity to connect with you today. And oh,

Scott Benner 2:32
that's crazy. I didn't realize that. I thought somebody put me in touch with you, and I didn't realize you knew who I was, honestly,

Paul Hanson, RN, BSN, CDE 2:39
absolutely I knew who you were, in fact. Little short story about us. You and I met at an insulate talk, I want to say, a national sales meeting when I worked with insulate, when I went to work for the corporate dark side and left, you know, clinical side of things. Yeah, you were there to give a talk, and I was in the audience, and I totally stalked you as you were coming out of the bathroom because I wanted to introduce myself, because was really a big supporter of you and your podcast. So I'm glad I didn't scar you, and that wasn't something that makes you stay up at night and not sleep, but that's how we first met. Yeah, I do

Scott Benner 3:15
have a scar from that day, if you want to know what it is. So I have a two fold scar from that day. I guess the first thing is, I had never given a talk to that many people before. Yeah, and I got it into my head, initially, to write out what I was going to say. And then, like, the day before, I was up in my hotel room, because this was, it was a national sales meeting. There were hundreds and hundreds and hundreds of people in that room, you know, because insult brings in. I mean, a lot of companies do this, but they'll bring their sales people all together once a year. And so I stood in my hotel room and I looked at what I wrote, and I thought, This is stupid. I can't, like, I can't do this like this, like, I just have to talk the way I normally do. I pivoted very late, and which made me nervous, because I was like, I had never really done nowadays. I just honestly, I just go up there. I'm like, huh, diabetes and go. But back then I was super nervous, and I got up there, and I was probably putting my whole heart into it, I would imagine. And at some point I recognized that was my first scar. Was being scared. My second one was when I recognized that a group of women and men, a mix of people in the front at the stage were crying while I was talking, and I didn't like it was the first time Paul I used to I get notes where people are like, Oh, I listen to the podcast, and it kind of makes me cry, or I feel emotional, and it's all like, nice, but I never had seen it in person before, and I almost felt like, sorry. Do you know what I mean? Like? I was like, Oh, I'm I'm like, I didn't mean to make you feel like this. And they were like, No, it's okay. And it just turned out that, you know, as in a lot of places, there are people working for companies that help people with diabetes that don't have diabetes, and some. Of them, don't. They're just selling a widget in their mind. You know what? I mean, like, it's the thing we make. And they're, they're moving along. But you have type one and, and I think this maybe is going to be why you're, you might be the right person to talk to today about Fresno. So how long? I guess? Let's give people just a high level overview. You've had type one since 77

Paul Hanson, RN, BSN, CDE 5:18
Yeah, January 2 of 1977 so, you know, that was, that was a long time ago. You know, that was when the cavemen were still around, and I had to, you know, dodge dinosaurs and hunt Willie mammoth to get my insulin. So how old were you then, Paul, I was four and a half. Yeah, okay. And truly, my first memory Scott is waking up in a hospital cold peanut butter sandwiches, because that was the snack that I was allowed to have, a mix of carbs and and terribly cold peanut butter. And watching my mom give injections with a at the time, monster sized needles into oranges, and that was my introduction into diabetes. Wow, to this day, I still love cold peanut butter sandwiches. That was a different reason why I was having it back in the day. Yeah. How Where are you on big needles? I'm not a big fan of big needles. I was right at that edge where they were getting into you know, I didn't have to boil my needles, luckily. But the needles back then were, I wish I could remember how big they were, but when I look, I swear I was like, it looked like an 18 gage needle. Holy cow. But I love the micro fine needles now and I, and actually, I do this every day with an ultra fine needle, with my long acting insulin trace needle, so needles don't bother me. I've given a gazillion injections, but it's not something I signed up for, yeah. So all

Scott Benner 6:33
right, so you managed back then. I mean, four years old, your mom, your your parents managed back then with what I mean, are you, oh gosh,

Paul Hanson, RN, BSN, CDE 6:43
ultra lente. Then, yeah, ultra lente and I was using porcine insulin back in the day. So insulin made from, you know, pigs, eventually, there might have been a mix of bovine in there. I, I'm not super clear on that, as you can as you can imagine. Then eventually NPH came out, and regular insulin was pretty amazing. So I was doing that, and I was injecting just once a day. Believe it or not, for years, I had a really And this speaks to the uniqueness of diabetes. But my MPH lasted for an abnormally long time, to the point where I would actually get nocturnal hypoglycemia quite a bit at night, and so they mph in regular in the morning, and then a little dose of regular in the evening. And that's what I managed for Honestly, all the way through college, really. Yeah, it's crazy. And then Lantis came out for me, and that was such a game changer, because you have diabetes, she's like, oh my goodness, I wish there was something more physiologic, more physiologic. And so when that came out, I got to go through the amazing fight with my insurance company, which I won't mention which one it was, about how I needed to have it. Long story short, I just said, Hey, no, no worries, man, just look forward to an ambulance call in the near future, you know, with the mph, you know, giving me issues in the middle of the night, and it'll be a good time. And you can pay for that, or you can pay for my Lantus. Yeah. They were happy to move along. Then, yeah, and then they paid for the Atlantis.

Scott Benner 8:08
Sometimes you have to say things on phone calls to get your get your meds, that's for sure. I've done it a number of times in my life, yeah, but you did regular and mph through college,

Paul Hanson, RN, BSN, CDE 8:17
yeah, yeah. I mean, remember I was, I was born in 1972 so we'll date me. Yeah. Awesome, yeah.

Scott Benner 8:24
So do you remember what your your outcomes were like then, like going back to college, for example, I

Paul Hanson, RN, BSN, CDE 8:32
do. I do. You had to be very regimented when you were on mph. And even with that regimentation, there was still going to be variation, just because, you know, the human body does what it wants to do based upon all the things that you're doing. So I would have to make sure that I had a snack with me in between, as I was walking through what's called the quad, I went to case, Western Reserve University in Cleveland, Ohio. And if I didn't have a snack, I would actually start to tank and get low in the middle of my walks. And of course, there are times where you're running late in one class and you're trying to get to the other because attendance in college for some reason in certain classes. In this case, I think it was statistics at the time, nursing statistics, you had to be in your butts and seat before the class started. So there were times where I would walk into a class and I'd be breaking out into a sweat. And it wasn't because I had had to run to class. It was because I was now having to fight off a low Yeah. Next thing you know, I'm I'm guzzling down a can of soda because that's what it was back in the day for me.

Scott Benner 9:33
Yeah? Jesus. Well, okay, so when you go to Lantis, I want to kind of jump through. I want to understand the different stops you've made management along the way, so Lantis is still your MDI there. I imagine diabetes comes with a lot of things to remember, so it's nice when someone takes something off of your plate. US med has done that for us. When it's time for art and supplies to be refreshed, we get an email rolls up and. In your inbox says, Hi, Arden, this is your friendly reorder email from us. Med. You open up the email. It's a big button that says, Click here to reorder, and you're done. Finally, somebody taking away a responsibility instead of adding one us. Med has done that for us. An email arrives. We click on a link, and the next thing you know, your products are at the front door. That simple, us, med.com/juice, box, or call 888-721-1514, I never have to wonder if Arden has enough supplies. I click on one link, I open up a box, I put the stuff in the drawer, and we're done. Us. Med carries everything from insulin pumps and diabetes testing supplies to the latest CGM like the libre three and the Dexcom g7 they accept Medicare nationwide over 800 private insurers, and all you have to do to get started is call 888-721-1514. Or go to my link, us, med.com/juicebox, using that number or my link helps to support the production of the Juicebox Podcast. Why would you settle for changing your CGM every few weeks when you can have 365 days of reliable glucose data? Today's episode is sponsored by the ever since 365 it is the only CGM with a tiny sensor that lasts a full year sitting comfortably under your skin with no more frequent sensor changes and essentially no compression lows. For one year, you'll get your CGM data in real time on your phone, smart watch, Android or iOS, even an Apple Watch predictive high and low alerts let you know where your glucose is headed before it gets there. So there's no surprises, just confidence, and you can instantly share that data with your healthcare provider or your family. You're going to get one year of reliable data without all those sensor changes. That's the ever sense. 365, gentle on your skin, strong for your life. One sensor a year. That gives you one less thing to worry about, head now to ever sense, cgm.com/juicebox,

Paul Hanson, RN, BSN, CDE 12:12
to get started. Yeah. So I changed Atlantis that was, I want to say that was 1991 to be honest, maybe 92 okay, I might be dating myself. Apologies, yeah, so I was on regular still for a little bit, and I would give it to myself, because they would cover the land just, but not the rapid acting insulin yet, but then, like, honestly, within a month, I just let them know that that wasn't going to work, because I wasn't having coverage in the middle of the day, and the last thing you wanted to do was take an insulin that might work, you know, eight hours or more with the regular insulin, and give it in the middle of the day. And so I was having issues. And then at that time, right? I was studying to, you know, be a nurse, and I really paid attention to the insulin action times. And I was like, Look, here's a map, or not a map, here's a here's a graph of how my insulin is working. I need to have this rapid acting insulin. And so eventually I was able to get that covered, too. And so then I began multiple daily inject, I would say, probably 92

Scott Benner 13:09
there. Okay, 92 you're doing. MDI, now. Do you ever go to a pump

Paul Hanson, RN, BSN, CDE 13:14
I did? I worked at Seattle Children's, you know, an incredible institution there, and I was blessed to work with all the different reps there and be introduced to all the different devices, including an old one, which I was really, I was a big fan of the Smith Del Tech Cosmo back in the day. It was that introduction into the different pumps, seeing the results that other children were having, and hearing what the reps were saying at the time, actually, and just my own personal need to make adjustments for basal based upon at the time I was a collegiate athlete, to plan soccer having to adjust my basal rates. I wanted to have more precision over the dosing of my insulin. So I did. I started on pump therapy. Gosh, when was that?

Scott Benner 14:02
The Cosmo? Was that your first pump? No,

Paul Hanson, RN, BSN, CDE 14:07
actually, the the Smith first pump was gonna be a decent Tronic, but that wasn't gonna be covered. And then decent Tronic was purchased by Roche diagnostics. So I then waited a couple years, actually, because when I first wanted to go onto a pump, I wanted to do something unique. I was seeing, I was being seen by my Endo, Swedish Endocrinology at the time, and I said, Hey, look, this is what I have to do. I'm an athlete, and I was pursuing professional soccer at the time. I was like, Look, I need to make sure that I can simulate as close to possible a decrease in the phase the basal insulin. So I want to start on my pump with 50% of my basal daily being given by Lantis, and then the rest of the basal rate being figured out based upon that daily Lantis. And so I had to sell them on the clinical benefits of that. And I said, Well, look, you know, one of the things that you teach is. If you have a site failure, there's a chance that you can go into DKA faster I go. Wouldn't you think that it would be better if I have this 50% basal to minimize that risk? And that was actually what allowed me to go onto a pump with 50% of my basal being given with Lantis insulin. At the time, that was probably 1990 or no, not 1990 that was probably 2000 and which is crazy, 2006

Scott Benner 15:27
well, 2006 Yeah, I'm wondering, like, you know, you're making charts to tell people, like, hey, I need this. Like that. Do you think it was the fact that you were in nursing school, or is it more about how your brain worked? Like, why were you tracking it? I mean, I've talked to so many people are like, look, they told me how to use the instant I put it in. It didn't work. Well, I didn't do anything about it. Like, why were you so on top of it, why were you the one suggesting bigger ideas?

Paul Hanson, RN, BSN, CDE 15:52
Yes, this is actually part of my story, Scott. I think a large part of it is, yes, I was a nursing student. But I think I was a nursing student because at a very early age, on my eighth birthday, or my mom asked my endocrinologist, not the most healthy individual, I'll save the specifics, but asked if she would have risk of having grandchildren with diabetes. And in an effort to try to minimize her angst, he actually said something that was pretty crass, and you said, if you have other children, you won't have to worry as much about it, but you won't have to worry about it with Paul either. A, there's a small chance in B, he'll probably have passed by the time he's around 30 years old. So now this is, this is on my eighth birthday, and you know you're, you're a kid, yeah, and you're sitting on the doctor's table and your legs are swinging, Scott, and you're just like, don't, don't, I'm gonna get a sticker. It's my birthday, and everything just stopped. And to be transparent, I was a meek little kid at the time then, because I went from being the tallest, most rambunctious kid prior to diagnosis, according to photos and and stories from family to being told that I couldn't participate in gym class, I was on a calorie restricted diet, and I went from being about head size, taller than everybody, to up until I was, gosh, 12, whatever, having calorie restrictions, and clearly, like being the shortest kid and not being able to participate in anything. And so I became very meek because I was told, I can't, I can't, I can't, I can't, you're sick. You're sick, you're sick. And so that was pretty tough. So on this eighth birthday, I got that note from the doc, as my mom is now crying, yeah, and she just wanted to know about the risks of grandchildren, and he, he said, the bus, get the bus stuff.

Scott Benner 17:44
Make some more babies. This one's gonna die soon. Yeah, yeah, yeah. It's really,

Paul Hanson, RN, BSN, CDE 17:48
it was really happy birthday. So I got up, I hopped off the table, and I walked out. My mom kind of lost her at me, because he didn't understand why I was leaving. And I was in in the lobby, and she came back. She's like, you need to come back and apologize to Dr blank. I'll leave his name out of this. And, Doctor, how's that sound? Yeah? Doctor, I said, Mom, I'm not, I'm not going to apologize to Dr butthead. I'm going to say butt heads, whatever you're good with. Yeah. Yeah. And I was like, I don't want to see him anymore. She's like, you will get back in there and you will apologize now where you're grounded. So I feel like that's kind of when I just woke up, not the conversation with my mom, but that day. So I walked back in to see Dr Butthead, and I let him know. I said, Look, Dr Butthead, you're fired. I don't want to see you anymore. You're not my endocrinologist. You're gonna die a whole hell of a lot sooner. I didn't say, Hell if I was an eight year old, but you're gonna, you know you're gonna die a lot sooner than I will have a good life. And I looked at my mom, and I said, Happy Birthday to me. You can ground me. And I walked back out, and that night, I gave myself my first injection. Oh, wow. It took about a half an hour because I had to overcome the fear of jabbing myself with this needle. And it lasted that fear for for quite some time. And I've got a funny story afterwards about, you know what the solution was? Yeah, I think that's getting back to your original question. I think that's why I became so focused on not being limited because of my diabetes like so I truly believe no limits. You know, I no limits. I

Scott Benner 19:25
mean, that's first of all astonishing, that at eight years old, you're like, I'm drawing a line in the sand right here. How did your mom respond? Did she relent on the grounding thing? Did she see your side of it ever? Because it's 1985 she also could have taken you out of the car, beat you amongst your head and shoulders. So I'm not sure what happened exactly. Oh well. So

Paul Hanson, RN, BSN, CDE 19:41
actually, it was, it was 1980 at the time, when on my eighth birthday, she did not relent. You don't know my mom, I was definitely grounded. I still gave myself my shot that night, and what I decided that day, it was something I felt. Got like this guy couldn't even take care. Of himself, and he's gonna put this diagnosis in on me. And I had been limited already so much that I said, No, no, no more. And I started to learn about the insulin even more the next weekend, I forged my my my parents signature. I'm really kind of speaking a lot to my character right now, so I apologize.

Scott Benner 20:17
What were you doing? No to play

Paul Hanson, RN, BSN, CDE 20:21
soccer. Oh, okay, yeah, because I wanted to play, I wanted to go be a kid, and I knew, if I could have, you know, my mom was and dad were excellent about making sure I always had snacks around because hypoglycemia was, it was nasty back in the day, and I've got some really scary stories about just paramedics being called in. You know that the course of adrenaline that's running through your body and them having to call in two sets of medics because you're just whooping everyone's ass as an eight year old, you know, kid, you know, weighing nothing. And so it's, it's just, it's not a great thing. It wasn't a great feeling. I decided that with this, you know, with sodas and juices and other things. I was going to go play soccer. And when I was found out that I did that, of course, I was grounded for that as well, but I just said, Look, I'm going to be dead by the time I'm 30, so I'm going to have died playing soccer.

Scott Benner 21:12
Yeah. Why not soccer? I don't even think I might get the women. So I got over, yeah, yeah. I got limited, limited horizons. Here it feels like, how long did you go along thinking you were gonna die in your 30s?

Paul Hanson, RN, BSN, CDE 21:23
Not long it was after soccer. Basically, I put that out of my mind as like, Okay, you proved

Scott Benner 21:27
it to yourself. You're like, oh, I if I did the Yeah. Here's another thing they told me I couldn't do. I did that. So they might have been wrong about all this stuff. It wasn't even

Paul Hanson, RN, BSN, CDE 21:34
that I just I was gonna do everything to spite Dr Butthead, and I was going to learn everything I could and try to do the best that I could. And I knew at a very young age, I you can see and feel, if you think about it, we didn't have sensors. We had, you know, test strips, that you're checking your blood sugar, but you were limited on how many times you can check your blood sugar. But as a person with diabetes, you can feel when your blood sugar is high. You can feel when it's lower, it's coming on. You know, others without diabetes might not understand this. There would be times where I would sneak something. I would sneak a donut, because I was done being told I couldn't have a donut, or this, that, or whatever. And all of a sudden, my muscles would ache, and I would go and pee on the ketone strip and make sure it wasn't getting too high. But it would show that, you know, you're spilling glucose and all that stuff. And so I saw the cause and effect, and I was like, Well, if that's the case, if I want to have a donut, and my insulin is working this much, but my blood sugar is going to this high after I have a donut, means I can't have a donut, or I have to give some insulin for that donut, which honestly, at the time, was probably a little silly, because for quite some time, I was doing that with regular insulin, but I was not allowed to go to birthday parties or anything like that until I was around 1314, years old, because of those challenges and not being able to have cake. And my mom was worried that I was going to eat cake because I would pack my insulin. And she's like, you can't go to the party. I don't want you giving insulin there. You might get low, and I would and I would tell her, I go, No, I'm not this. Insulin is not going to kick in for the next two, three hours. I'm going to take one, one unit so I can have a piece of cake. Let's not prescribe like that. You can't I go, Yes, I can. This is how it acts.

Scott Benner 23:13
Yeah, I've been doing this. I'm paying attention. This is how you know, it's funny, Paul, your story. So mimics a situation that I had where I think a well meaning medical professional told me that I shouldn't worry about Arden's blood sugars going up and down, because it takes like, 30 years for diabetes complications to happen, except when she was telling me Arden was two, right? And so I stopped her, and I said, So you're telling me that when my daughter's 30, she's gonna have complications, and then there's that dead look, you know, that's there. And I go, that's not comforting, you know, in case, in case, she thought it was, and I think that might have been about the time that I thought I'm gonna have to figure this out, because I don't think anyone else is gonna help me. Yeah,

Paul Hanson, RN, BSN, CDE 24:00
yeah. Gosh, this could be an entirely other call, and it speaks to the challenges within, you know, endocrinology itself, and the support and all that stuff. But I do think we're still blessed within the pediatric space to have the support that we have. I've met

Scott Benner 24:13
a ton of good people along the way, and that person, by the way, was valuable to us throughout the it was just that one moment where they, I think, people don't think or Well, I mean, Dr butthead seemed a little more unnecessarily direct. Like, maybe, hey, why don't we let Paul go outside for a second while? I let you know that you should keep procreating if you want grandchildren without diabetes. Like, exactly, by the way, do you have brothers or sisters?

Paul Hanson, RN, BSN, CDE 24:35
I do. I'm the oldest of six, and none of them have diabetes. Wait. Your mom listened, though, huh? Yeah, man, she cranked him out, and I didn't even get a sticker that day. Scott, well, you

Scott Benner 24:50
know the downside of this is your dad probably loves the doctor,

Paul Hanson, RN, BSN, CDE 24:55
or does he? She also has six i.

Scott Benner 25:00
So I think what we're highlighting here, and I'm glad you know that you were able to share this, because I'm trying to figure out how you get to inhaling insulin, because it's a leap, but now it's not a leap for a person like you, and so now that makes more sense to me. So you did pumps. You did i I'm gonna jump ahead now to for us, if you don't mind, I'm sure you tried pumps along the way. Everything else. Where do you first hear about inhaled insulin? What makes you start trying it? What did you experience early on that kept you going? Yep,

Paul Hanson, RN, BSN, CDE 25:30
I met Al Mann at an ADA event. I want to say it was, might have been the one in Washington, DC. It was some famous anniversary for the ADA. I can't remember what year it was. Al Mann himself was there in front of a video screen talking about this insulin. And for anybody who doesn't know Al man he's behind the creation of this inhaled insulin of Fresa. He created the company mankind. And I was so enamored by what he was discussing and the implications that it could mean in the diabetes space. Let's step back a little bit selfishly, just for me as a person that wanted to have something that was more physiologic, I would still, at the time, have challenges with my pump, and it was always centered around meals as a result, you know, I would know certain holidays or whatever, my blood sugars were going to be a little caddy Wampus for a while, and that's just what you did. Or at least that's what I did. What this meant for me was there was an opportunity and see if it could help with those challenges. Like, honestly, Scott, I I suddenly would have cereal until I started on a Fresa, because it was going to be a show, I could guarantee I was going to shoot up into the three hundreds. And then I was definitely going to stack my insulin. Because, you know, you try to get on top of that. It doesn't matter if you give it 30 minutes beforehand, at least in my case, because everybody with diabetes is different, I would still go up, and that was just based on, you know, the cereals. And so I was like, Man, this is a physiologic mimicking insulin that's getting into the lungs, which means it's getting right into the bloodstream. They differentiated it from the inhaled insulin exuber Which, you know, came out when I was working at Seattle Children's. And I was like, this, this could be a game changer in the diabetes space. So I watched it for a while. I kept watching it. Unfortunately, Al man passed mankind and Sanofi Aventis kind of partnered early on, and my perspective was that they took more of a type two route versus a type one route, where I was surprised by that choice. And this is just Paul Hanson as an n of one making that decision, because I saw in the type one space, the fact that we are so impacted by the need of insulin at all times, versus, you know, the

Scott Benner 27:54
type two space, and the speed of it being so important too, yeah, and

Paul Hanson, RN, BSN, CDE 27:58
the speed of it being so important and the fact that it cleared so fast, so honestly, I started on it about five years ago, okay, and the first thing I did was I was with a friend. I didn't get their permission, but he's in the diabetes space, and I can ask for forgiveness, but I was with two friends, and I'm going to share their names, and I'm going to let them know, Scott, unless you don't want me to, but it was Brian Lee and Gary Yamada, two very close personal friends of mine. Brian was actually working for mankind at the time, and he had been telling me about it. And so I ended up getting some of, you know, my own a Fresa, and we met, and I was like, Yo, I'm so excited about this. I want to get an obnoxious meal, and I want to test this. So we, we all met down in Southern California. I had chicken and waffles with regular gravy, knowing that it would it would have devastated me on my pump, yeah, and so what I did was I had my pump for basal and increased it, and then dosed for that meal. And honestly, I didn't get above, like, 180 200 and I was like, wow. What I noticed, though, is I needed to dose a little a little bit more later, you know, probably about two hours later. Okay, I recognize that this was going to be some learning for me, but I did not go into the three hundreds. Yeah, and I don't feel like for me, my muscles ache. I get cloudy a thought. I just don't feel great, dry mouth, all the fun things. So the next thing I did was I hadn't had a bowl of cereal. I sat down. This is when I came home and I asked my wife to pick up some cinnamon toast crunch. So of course, my kids, who were younger at the time, were like, sweet. I'm like, Look, Dad's getting the first bowl. And I had a college size bowl of Cinnamon Toast Crunch. And again, I dosed with more confidence, with a little bit more of the and I didn't shoot above 180 and, you know, I came back down like, probably. Just finished up at around 150 that That, to me, was such a game changer. To be clear, it's it was a process for me because of the fear of hypoglycemia, I

Scott Benner 30:09
would imagine, yeah, because you'd had diabetes for such a long time, and it's so ingrained in your head about, you know, mph and how long it lasts, and you got to eat at the right times and all that stuff. But that probably makes you a better, you know, navigator of learning this new thing too, yeah.

Paul Hanson, RN, BSN, CDE 30:27
And honestly, if you think about it, hypoglycemia dictates the actions of anybody with diabetes, of parents with children with diabetes, it's, you know, we want to prevent that, I mean, for obvious reasons. And so I was slow in my uptake of utilizing it all the time. I would probably use it for one or two meals a day, probably about three years ago, I went to it full time. I went to traceba, because for me, that insulin worked really well as far as basal control, as well as being able to exercise and not having the basal insulin itself drive me low as a result. And again, I'm an n of one. That was my result. And then with the ephraza and I've been for the last three years on a Fresa and placebo, the best I can get, my ANCs were around six three to six one, and they dropped to a five nine to a five seven. And I've actually had a five three, and that's with hypoglycemia ranging one to 3% only, wow, and, and that's a big

Scott Benner 31:28
change. No, that's huge. How would you describe your eating style? I'm still lower

Paul Hanson, RN, BSN, CDE 31:33
carb to be honest. I just, that's just my choice. But come holidays and stuff like that, I'm not limited anymore to having these desserts and worrying about my blood sugars. Early on, I put on a little weight because I was a little too excited. I was

Scott Benner 31:48
gonna say you were just like chicken waffles. Great, by the way, chicken waffles and gravy. Way to go. You're like cereal. What else I bet you were? I actually you know what I thought to say earlier. I bet you, Dr butthead and you had more in common by the time you figured out a phrase.

Paul Hanson, RN, BSN, CDE 32:05
It didn't get that bad, Scott, but honestly, you think about all those years of not being able to do things, and I probably put on eight pounds, okay, that was also after a knee surgery. So there's a combination of things, but that all being said now, exercising, you know, ex pro soccer player, I eat what I want, and I don't have to worry about it. My wife is Cambodian sticky rice, all the yummy things. I eat what I want, and I don't have to worry about the crazy spikes.

Scott Benner 32:35
Yeah, no, it certainly is. You're not a high carb all day person. But no, if you run into something now you would have ignored it in the past, and now you say, Oh, I'm going to give this a shot, because I feel like I can kind of crush this spike and stop it from happening, and I'm going to get a rise still, but not something that makes me feel terrible, or that lasts for four hours, or that ends with me crushing it and then having To catch it on the back end

Paul Hanson, RN, BSN, CDE 33:00
Exactly. This is the thing for me. And I shared this early on, because of the fears of lows. There'll be time when i times when I had dosed incorrectly, I had to give myself more, you know, an hour later, because there were times where I did estimate wrong, right? You know, you're carb counting, and you're doing all these things based upon in the past, I had an insulin to carb ratio and insulin sensitivity and and all that stuff. You know, you're putting together your best guesstimates. There are times because there is no perfect science with diabetes. I feel or it's very hard to get there. I did have to. I definitely missed dosed. But again, that was my my fear of lows, right? And so part of my journey with dosing of a fraza was the embracing of the fact that you had to always take about one and a half times the amount of the insulin that you would normally give with an injectable insulin. And in all honesty, you know, it's, it's kind of out there with mankind's peds trials, they're testing it at two times the dosing. And that's actually what I ended up finding myself is that I had to, I had to take around two times as much insulin, and so that that can scare a lot of people because of the fear of hypoglycemia. I want

Scott Benner 34:09
to dig into how the dosing works and everything. How long do you think it took you to figure out the dosing? I

Paul Hanson, RN, BSN, CDE 34:16
want to get this out for everybody so they know this. Again, diabetes educator, nurse. For a while. I did work for mankind, so I need to get that out there. Yeah, please. And even with that, though, because of my own personal experience with hypoglycemia, it probably took me nine months, okay, to a year, truly just me, because of my own you know, I, I don't, because you took to it because of the path, because I don't want to be a burden on my family. I don't want my wife. She has never had to call the paramedics, never had to deal with glucagon. She's never had to do that. My kids haven't had to see that. That's a driver for me, yeah, and so in those instances, I would probably run the risk of being a little bit higher because I knew that you could. Correct sooner, because it clears so fast, and that was the route that I took. That was my route.

Scott Benner 35:06
All right, so the reason I was am so excited to have you here is because I feel like I've talked to a handful of people using it at this point, and they've all done a great job of telling their story. And I'm certainly not, you know, saying otherwise. But I always end the conversations feeling like no one's been clear about how this works. Like, you know, you know what I mean, like, I know with like, you're using liquid insulin. It's insulin to carb ratio, it's insulin sensitivity, factor, it's, you know, it's your basal. Like, it's these, these things, right? And now there's algorithms that are that are moving, you know, dosing around for you within parameters, etc. And if you ask somebody to explain that, they can explain it, yeah, like, here's the formula I use to get to my insulin to carb ratio. And so when I count up 50 carbs, I take, I'm one for 10, so I take five units and, like, that kind of thing. I ask somebody on a pre to this, and they're like, oh, you know, a four and an EIGHT and a 12, and do you do two? And you wait one, and I'm like, I don't know what you just said. Like, like, so. And what's worse is I don't feel like they know what they just said. Sometimes, yeah, so please tell me I'm gonna

Paul Hanson, RN, BSN, CDE 36:17
try to expand upon it, okay, the way it would, and I had trained patients on it and stuff. Starting orders for this are, if you're taking up to four units of injectable insulin, four units of a fresn, but anticipate that your end dose is going to be an eight, okay, for that meal type, okay. Now there is a precision that we perceive that we have with injectable insulin based upon some crazy things, such as, we exactly know where we are, physiologically, we have absolutely crushed our insulin to carb count, in spite of the fact that, you know there is, I think, allowed up to 20 plus percent variability on the food labels, as far as carb count and all these things. And you know, you could, you've heard the story over and over that you could put a meal down in front of a bunch of registered dietitian dietitians and nurses who they do this for a living, and you're going to get such a wide variety of of carbohydrate estimates right. And so with that, we try to get as precise as possible. And I think we have tricked ourselves. If you take away the A I D component, automated insulin delivery, and you just go back to generic MDI and pump therapy, we have convinced ourselves that we've got a very precise algorithm, and it's exact. Yeah, I agree with you. That is just not true. Diabetes is complicated.

Scott Benner 37:40
When people say, I can do one thing one day, the same thing the next day, and two things that you know, like, You're not exactly are you dehydrated today? Were you less active yesterday than you were the day before? Like, you do your best you can right? Like, and so I assume the same is with a fresn. But like, just to start off by saying, like, Hey, if you're, you know, injecting insulin right now, and you're moving to a fresn, and normally this meal is four units. Well, it's probably going to be eight, but you also just said that the studies might indicate that it could be 16. So like, how do you figure it out?

Paul Hanson, RN, BSN, CDE 38:13
This is exactly what it is, right? You take what you would be given at that meal and one and a half times it, and you then round down, and that's for safety, for fear of hypoglycemia. You then check your trends one to two hours later, and if you're having to correct one to two hours later as a result, that then means that that dose was off probably by four units in that case. And just like anything, just like when you go onto a pump and you're having to call into the diabetes educator, and you're having to have basal rates adjusted, and you're having to have insulin to car races adjusted based upon two or three days data, and then you're having to do the same thing two weeks later, because now that data is incorrect and it's not working any longer. The same thing is happening with your friends. It's an if then statement from a safety standpoint, one and a half times round down if you then need to correct at that carb count with that meal type. Then next time, give yourself an example like this, an additional four units. It's really that simple and what, and I view it as simple, because I've done it, even though it took me a year. But my path, for me, it was year of lows. That was that reason, right? Not, not the precision. And what I have found is that I can look at a meal and it's more carb recognition versus carb precision, yeah,

Scott Benner 39:32
like this meal takes about this much. Yes, yeah. I mean, that's how I taught my daughter to do it as well, right?

Paul Hanson, RN, BSN, CDE 39:39
Yeah. And for anybody that is, how could I say this, at risk of underdosing and then later on stacking, or, let's talk in general, how hard is it to dose 15 minutes to a half an hour, depending on your blood sugar in advance, so that that insulin? Is ready to rock and roll as you're digesting your mixed meal with, you know, fat, protein, carbohydrates, etc, etc. It's not easy. And so the challenge that we see with a lot of patients, and I've faced this when I was in the clinical setting as well as, you know, on on, I say, the commercial dark side of things is that patients know so many times that if they sit down and they're giving their insulin at the start of a meal, the perception is, is that they're failing because of how hard it is? Oh sure, yeah, so that that kind of stinks. And so with for me, the reason I chose to go on a Fresno was I got to that point where I recognized carb recognition, and if I needed to, an hour later, I can give myself a correction, and I hear a lot of Doc saying, Oh, I can't even get them to give their insulin. How are you going to get them to, you know, to take it more insulin. An hour later, I would always just push back and be like, hey, just with all due respect, diabetes is hard, and this is an incredible option for those patients that and I'm going to push back even more doc that are taking their insulin, they're just taking it at the time that they eat, and that means they're not actually they're reducing their risk of success.

Scott Benner 41:08
It ignores how insulin timing works. You know, liquid insulin timing works, right? So I take all your points too. Like, you know, if you know you have to Pre Bolus and you don't, then the meal already started, when you're just like, Oh, I already screwed this up. Like, that feeling right? And then your blood sugar shoots up 1015, minutes later, and you're like, oh, here it comes. I do, like, not disagree, but like, I do think that it's okay to Bolus again. I'm not a person who says that. Like, oh, well, you know, the insulin action time is three hours, so you're gonna sit here and stare at this for three hours. My opinion is, if you missed on the dose, and your blood sugar shoots up, obviously you needed more insulin in there. Yeah, the sooner you put it in, the better, honestly, because at least then it's still working against the impact of the food, right? If you need it, I don't think you can stack if you need it,

Paul Hanson, RN, BSN, CDE 41:56
and I agree with you in that case, right? Because what happens is, A, you know, you messed up on the carb count. B, now your blood sugar is climbing. C, there's something called glucose toxicity, which then makes you insulin resistant to the quantity of insulin that you're taking in. Yeah. And so there's all these different factors that go into those, those times right, where it's really hard to say you're not going to stack, you know you're not going to give yourself more insulin. I don't

Scott Benner 42:22
have to Pre Bolus. Fresno, oh, you sit down

Paul Hanson, RN, BSN, CDE 42:26
and you eat and you take your insulin. And for for those with like, say, gastroparesis or others, they can actually wait until their CGMS are starting to trace up, and then they dose. They hit it there. This is the way it works. You inhale. It's in your lungs in less than a second. It's in your bloodstream in less than a minute. It's already an insulin monomer, which is the usable form of insulin, which the hexamer, or a monomer, bound upon itself six times, is actually breaking down into in the body to be in usable form. And now you're just you're inhaling it. It's a monomer. It's in your bloodstream in a minute. And you know, it's peaking and not peaking, it's starting to have a measurable effect in around 10 to 12 minutes. And this is all in the prescribing information the PI. It's mimicking a peak of physiologic insulin when you have a closed clamp study of around 45 minutes, right? And then the insulin response for somebody without diabetes. So it's pretty amazing, to be honest, there is the nuance of having to learn how to heck do I dose with this? And how do I overcome my fear of lows with this? I do want to say real quick, and we can put a pin in this. I also think the lows are different with an Ephrata than other insulin. My I'm not in front of the fridge inhaling because I know I might have three more hours worth of insulin in me if I, if I do get a low, instead of taking 15 grams, now I might take four to six grams. And I have these gels that I take that are, you know, around eight grams of carb, because it really just depends on, when are you having that low? If you're 45 minutes to an hour into your inhaled insulin, gosh, almost out of your system. So you don't need 1520, or a fridge full of food, because you've got hours of insulin, you know, sitting in your system. So there's that benefit as well. What

Scott Benner 44:10
number do you call low for me? 70? Okay, you would treat a 70. If it was falling, if I was

Paul Hanson, RN, BSN, CDE 44:17
falling at a 70, I would definitely treat that, I will tell you also something unique about amafreza. My understanding with the CGM is that their algorithms are based on 20 minute predictive values, right? And CGM technology is changing a ton, so I apologize if I'm Miss speaking slightly about any of the newer ones that have come out, but it's predicting where you're going to be. Well, the rate of change with the fresn, because it's so fast, is is different than injectable insulin. And so there are times where I've actually had a blood sugar that's been 100 and it's had a double arrow down, and I was like, Hey, when did I take my fressa? And I look in it, and it's like, oh, it's was 45 minutes ago. Up. I don't stress about it. I watch and I wait and I see how I feel, and 15 minutes later, my CGM will level out, and I might be 9295 but it thinks, because of that rate of change, that it's going to continue for that a long duration, because that's what happens with injectable

Scott Benner 45:20
insulin. Let me ask you a question. Uninjectable. You know, if I said the phrase, you can feel the fall, you know what I'm talking about, right? Oh, absolutely. It's Oh, yeah. Does that happen with a Fresa? I

Paul Hanson, RN, BSN, CDE 45:32
have not experienced that, okay, however. Well, now I want to back that up. I have experienced it, but it's not this anxiety ridden again. Have to get in front of the fridge. It's, it's the only, only thing I can describe is that it's different,

Scott Benner 45:49
yeah, because it feels physiologically different, or because you have a different feeling about what the outcome is going to be, combination

Paul Hanson, RN, BSN, CDE 45:55
of the of the of the two. Okay, right there. There are times where, if I've eaten a fattier meal, and it's slower to absorb, absorb, I have actually started to go low. It's made me nervous, especially if you know you're out and about with people. And so I will take an eight, you know, a quick eight, a hit of an eight gram gel, and I'll just continue to watch. And there are times where I've actually felt it and I started to sweat. That's another one of my physiologic things is I start to sweat. And it doesn't happen frequently, but when it does, those gels come out pretty quick. You know, they help me very quickly. And then what happens is, I know that that fatty meal is gonna drive me up later, so I just watch it. I was gonna say, dose again later. Do

Scott Benner 46:45
you use a Fresno, like, like, you know, like, thinking back to, like, an old square wave bowl, a certain extended bowl, the dual waves and all those, yeah. Do you put in some, like, you know, let's use, like, a real cheesy meat lovers pizza idea. Oh, 100% do you put a little bit in up front and then come in, what, 45 minutes an hour later, and hit it harder.

Paul Hanson, RN, BSN, CDE 47:04
I am so glad you asked me that question, because, man, pizza is such a pain in the butt. But, yeah, let's, let's, let's get even crazier. Let's go, you know, Dick crust, let's go, you know, Chicago style pizza.

Scott Benner 47:16
It's not really pizza, but go ahead. I'll, I'll allow this. Go ahead. Okay,

Paul Hanson, RN, BSN, CDE 47:20
I appreciate that.

Scott Benner 47:21
I know you're from Ohio and everything, but I don't think that counts. But go ahead,

Paul Hanson, RN, BSN, CDE 47:26
it doesn't. That's actually, yeah, that's a gut bomb. I hear you, but yeah, I'll dose more up front than I'll dose 45 minutes later, and I do dose every 45 minutes. Just to be clear with pizza is the concoction of the fat and the meat and everything, and the carbs I want to get on top of the carbs that are going to break down quickly. And so, you know, usually I'll take an eight there, and a pizza is going to be the dish that I take the most insulin with, for me, with my insulin needs. Yeah. So I'll usually take an eight, and then 45 minutes to an hour later, I'll take another eight, and then one hour later, I'll probably take another eight, and that's for, you know, two to three pieces of pizza. And I'm having to dose three, minimally three times for pizza. There are times when it's four, okay? There are some people say, just dose up front heavily for that. I have not had a good experience when you do that. The reality of it is, is this drug you down too far? Well, yeah, and this is a deal, and this is something I don't think is very commonly known. So at the smaller doses of friends of clear is super quick, right? Okay, but when you have larger doses, it does take a little bit longer to clear, okay? And so that might be some of the you know, the clinical rationale to just take more upfront if you're going to need that. I with hypoglycemia and the fear of hypoglycemia being with a driver, take a different approach as a person with diabetes, which is, I'm going to dose a good amount up front, and I am willing to dose, you know, three or four times so I can, a, enjoy that pizza, but B, avoid that risk of a low I

Scott Benner 48:53
think. Okay, we haven't gotten into this part yet, but you're inhaling it, right? So, and they're in little disposable like cartridges. Like cartridges, okay, how many of those do you think you use in a day? It depends, right?

Paul Hanson, RN, BSN, CDE 49:05
If, if it's a pizza day, then it's going to be significantly more standard day. I probably use between three to five.

Scott Benner 49:12
Okay. How do you carry them with you? They're in your pocket. Do you leave them in your car door? Like, how do you imagine

Paul Hanson, RN, BSN, CDE 49:18
an Altoid tin? Right? I went to training patients and when and for myself, I just went on to Amazon, and I found these black TINs that look like Altoid tins because I didn't, you know, want them to be minty fresh smelling as I inhaled them. And I get that the inhaler goes in there, and then I take out the cartridges that I need for the day. And I put them in there. I take them out of their foil wrapped and I put them in there, and they carry them with me. And so once you've taken them out from that little foil wrap, and they're and they're loose, they're good for three days.

Scott Benner 49:51
Okay, out of the like, refrigeration or not refrigeration, no,

Paul Hanson, RN, BSN, CDE 49:55
out of the foil wrap itself. So got a larger foil wrap. Package, and then in it, right? That's got rows of additionally foil wrapped containers, right? And each each row has three, so you'll have 30, and then an entire foil wrapped package. What I do is I usually take a row of five out, so five times three, so 15 cartridges, and I leave that in my my diabetes draw. And each day I'll go and I'll take section of fours. So I'll take three fours and and three eights, and I open up that portion, I put them into my little tin, and that's what I carry with me. And that's, you know, to me, this to me, that's not a big deal. Okay? I either have it my jacket pocket or my work bag. You know, in the past, I would carry it in my pocket. I've seen tons of people that actually will just take their inhaler, put it in their pocket, take their their crutches with them. That's just not a choice I made. Did

Scott Benner 50:53
it ever occur to you when you were making the switch, like, maybe I'll just stay, like, on an A I D pump and then use a phrase that a crush, like, big highs and stuff like that.

Paul Hanson, RN, BSN, CDE 51:01
Absolutely, it totally did. I was at this point where I had to make a choice. I started to have some abdominal irritation with with the pump sites and with Dexcom sites or sensor sites. And so I really had to prioritize, where is what skin space is going to be used, and what's going to be the priority? And so I decided to go off of a IDs, because the importance of the sensors is so important to me. Earl Hirsch has done a bunch of, you know, work on this, and does mention that, you know, with tan, yeah, you can have increased sensitivity and challenges with with using adhesive over long periods of time. And so I just went on a break. And what I found for me was that perceived and afreza is what I liked. However, I have considered going back onto an A I D, using a Fresa with it to overcome those because again, the A I D, S man Scott, were blessed in this time where we have all these incredible devices. Like, seriously, like, if I was eight, and Dr butthead was going to tell me that, and I had foresight, and I could say, Yeah, guess what? Dr Butthead, you know, we're going to have all this technology in the future. And, you know,

Scott Benner 52:13
yeah, what do you say? What's making you is it just how great the A IDs are, like, or what's making you think about going back that way.

Paul Hanson, RN, BSN, CDE 52:21
How great the A I D s continue to get. They continue to get better and better and better. And I don't want to really name systems, but like, they just, gosh, I, I'm so impressed with them, yeah, like, like, truly, you think about when they first came out, you know, we, you know, we had Medtronic and we had some, you know, we're doing their thing, and tandem and and Omnipod, and now you got PETA bionics, and you've got SQL med tech, and you've got all these options for all these different patients who have all these different needs. Yeah, man, it's, it's incredible, like, purely, no,

Scott Benner 52:55
really is. How about insulin sensitivity for, like, use a menstruating woman as an example, right? Like, my daughter's uh, needs change pretty consistently through the through the month. Does that change along with it? Or is a fressa insulin? And this is going to sound stupid, because I'm pretty sure I know the answer, but I'm still going to ask the question, because I think it helps people understand. Like, is there anything about a fresn that makes it insulin sensitivity proof. Or, do you know, I mean, like, my sensitivity rises, my Ephesian need rises as well.

Paul Hanson, RN, BSN, CDE 53:26
Yeah, if your sensitivity changes, your need rises. That's just, that's a physiologic thing, and so you just need to take more insulin. It's as simple as that. So if, if she's gonna be more resistant because of, you know, her menses, then she's gonna, she's probably, no, not. Probably she's gonna need to take more meal time no matter what. Just like, yeah, yeah, it is what it is, right? Physiologically, your body is saying, hey, the insulin you normally doesn't make isn't gonna do the job, so it would naturally just create more insulin. We now have to supplement that. So

Scott Benner 53:58
Paul, what would you do right now? Currently, the way you're managing if your blood sugar was 115 and it had been 115 for six hours and it was not going to change from 115 and you thought, I really want my blood sugar to be 95 Can you do that with a frozen or is a four gonna move you too far in a situation like that? I know it's just for you personally we're talking about. But like, I'm trying to figure out if you can be more precise with it, or if you need to work in bigger like, you know what? I mean, it's

Paul Hanson, RN, BSN, CDE 54:25
a good question. Is a good question. So, very, very good question. This is not FDA approved. Uh oh.

Scott Benner 54:30
Are you about to tell me? You go and then, like, spit the rest of it out. Let's go, no,

Paul Hanson, RN, BSN, CDE 54:35
no. But you know, I don't know if you've, like, seen the movie Serpico or anything like that where they have glass mirrors out. I've heard, let's just say I've heard rumors of multiple individuals, and I'll even say I've done it myself, or I've taken a four and I've opened up the contents and, again, not FDA approved. Do not do this at home. We're not giving medical advice. I know that that four is going to drop. Me, let's say 60 points. I will take a half of that, put it back in the container, put it back in the cartridge, and inhale half of it.

Scott Benner 55:08
Wait. How the hell do you do that? Like, by the way, I thought you were telling me you were snorting it, so I wasn't sure what was going because you were like, you're like, mirror Serpico. I'm like, is this like a an odd code reference? What's going on here? No, no, sorry. I mean, no, no, don't be sorry. Like, can you explain it? Like, listen nothing you hear on the Juicebox Podcast should be considered advice medical or otherwise, always consult a physician before making any changes to your health care plan. Now, Paul, what do you do? I

Paul Hanson, RN, BSN, CDE 55:33
will, in this case, let's say I'm 120 or whatever, and I want to be 90. I will take out a blue which is a four unit cartridge. I'll open up the cartridge, and I will put it on a I'll put it on a mirror, and I will take half of it, put it back into the cartridge, and I'll inhale it, and I'll end up at 90.

Scott Benner 55:50
I know I don't know what you're talking about, but I'm assuming somewhere online, someone is like you. You spray it onto the mirror.

Paul Hanson, RN, BSN, CDE 55:55
No. So the cartridge itself is broken up, so there's, there's blue tops, like a white bottom chamber that has the the powder in it, okay? And so what I will do is I will separate the two so you can access the powder. Okay, okay. And then I will take that powder, I will put it on the mirror. I will then take a half of it, and I will put it back into that cartridge, reconnected to the blue top, and then I will inhale it. And this is absolutely not something that don't

Scott Benner 56:29
do this, but like

Paul Hanson, RN, BSN, CDE 56:30
at all, but that is the only way, in that case, if I want to go to bed and be 90 and I'm at, say, 120 and I want to go through the night, because I'm one of those type A personalities. And so I have heard, let's just say that others do that. And I have tried it, and it has worked. Listen,

Scott Benner 56:51
I say, steal a 1c overnight all the time. Like, if you can be lower and stable, like, I don't mean low, but like, you know, if you're 130 and you could be 90, then let's go for it. You know what I mean, right? And

Paul Hanson, RN, BSN, CDE 57:01
if you can be 90 for eight hours, yeah, the impact on your A, 1c, and just, just everything, it's awesome.

Scott Benner 57:07
Actually. It feels to me like you like it, but it doesn't have as fine of control as you need. And that's understandable. What about breathing issues? Like, have you? Do you get a cough? He's like, I have to tell you when, when a Fresno first came out, and someone said to me, because people come to me and ask me, like, Hey, are you gonna do this? And they said, you know, are you gonna do this for Arden? I was like, Look, that seems like another step of complexity that I don't need, having my kid inhale something, and I don't, I could have been 1,000,000% wrong. I have no idea. It just was a knee jerk reaction. Some people do have issues. Right

Paul Hanson, RN, BSN, CDE 57:42
again, if you take a look at the prescribers information, or the PI again, it's not recommended for anybody with asthma or COPD, because there is a risk of bronchospasm. But if you think about inhaling, gosh, some type of NDI inhaler, or even, you know, some other inhalers that are preventative for asthma, and you're inhaling a powder, you run the risk of a cough. It's just, it is what it is. You're inhaling a powder. So at the larger doses, if you just start and you're somebody that has a larger insulin need. Yes, there is a risk of having a cough. A cough is non progressive, and it tends to dissipate with time. There are also strategies that you can use that, such as taking a sip of water before and after, to minimize that risk. When I started, did I get a cough? I did not with the four unit cartridges. Sometimes with the eight unit cartridges, you have to be aware of it. It's something that tends to go away pretty quickly, usually about about two, three weeks, if you get that, did I have throat irritation? I did. I had some throat irritation when I started to inhale. It did that go away as well? It totally did. Okay. You

Scott Benner 58:51
didn't panic. You didn't go, oh, great, I have throat cancer. You didn't like, you know what I mean, I didn't

Paul Hanson, RN, BSN, CDE 58:55
panic about, you know, do I have throat cancer or anything like that? Medically, if you go back to my earlier part of the conversation, I thought, I thought this through. I mean, this is not sitting in the body or in the lungs for a very long time. It's literally in the lungs in less than a second, in the bloodstream in less than a minute. So I don't have to worry about anything going on there in my lungs, broke cancer, or anything like that is dissipating. It's being broken down. I mean, it's, it's it's getting out of the body and the FB KP, which is the carrier particle. It's called femural day keto pipe pairs. It's in art. So I, being trained by mankind, when I worked for them, knew this. I didn't stress about it, but it was something that, as you know an athlete, I did worry about. They have you do an FEV one or force expiratory volume, which is part of a larger thing called a pulmonary function test. They have you do that at the start, and providers are able to follow that and see if you have any you know, change in FEV one, or you know your force exporatory volume. I do not some people you know can have a change. Of they say, if you have a 20% change from your baseline, then the you know, your doctor should consider whether or not you come off of therapy. Okay, you tend not to, you tend not to see that.

Scott Benner 1:00:12
Well, do you have any idea how many people actually use it?

Paul Hanson, RN, BSN, CDE 1:00:16
I wish I had the exact numbers. I really do. I want it to be, and this is just me. I personally, as a person with diabetes, think this should be something that should be in everybody's tool kit, to be honest. You know, Scott, I get glucagon every single year, and I haven't used it, thank goodness, for 20 years, but I get that prescription. And so what I wonder is, is, are there are opportunities for individuals to get one or two of these prescriptions in a year. Practical, yeah, to deal with those circumstances, you know, where they've had a site failure, or they are going to go crazy, and they're not only going to have a Cinnabon, but they're going to get Carmel put on it, and they're going to have ice cream, and it's going to be one of those crazy days. I'm interested to see if that's an approach that is taken in the future, you know, by providers patients in their asks, for example, and will insurance companies allow it? I mean, that's just, that's another conversation altogether.

Scott Benner 1:01:11
That was my last question is, you know, is it covered by everyone's insurance? Even,

Paul Hanson, RN, BSN, CDE 1:01:16
yeah, great question with anything that is really beneficial to a person. Of course, it's not going to be covered by everybody.

Scott Benner 1:01:23
For you. No, probably not, yeah.

Paul Hanson, RN, BSN, CDE 1:01:26
So it's really, it's incredible for people with type one and type two diabetes. So of course, it's not going to be covered right away. As a first line, you have to do a prior authorization in most cases. Now, with the prior authorization, what I do know about, you know, mankind, they've done a ton of work. They've got a process where you can get it covered with that prior authorization. So that's not an issue, honestly, it's just, you know, you have to continue to fight. And it was the same thing with CGM and pumps, you know, honestly, for upwards of, like, 10 plus years, until the clinical, long term efficacy of these of this was shown. The thing

Scott Benner 1:02:04
that scares me about Fresa is I, first of all, I, generally speaking, I agree with you. I wish more people had access to us. They could try it. We could get a better understanding what people think, because you always end up talking to somebody who's just like, you know, all in because they know, but it's not growing. You know what I mean? Like, you know when you hear people talk about, like, I loop, and it makes it sound like everybody's looping, but really, there's not that many people doing it, compared to how many people have diabetes, right? Yeah. Like, that's the other idea. Like, I wonder if, like, is it going to get its day in the sun because it's been around for a while, it's past hands already. You know what I mean, from companies like, How long before somebody's just like, sing, catching on, yeah. And then we don't ever get a chance to really, as a community, absorb, you know, the knowledge that that comes with trying it to see if it's a thing that could, you know, spread. Does

Paul Hanson, RN, BSN, CDE 1:02:56
that make sense? Yeah, I know it totally does. And I'm gonna answer your question with a question. Oh, good, yeah. Do you think that overcoming clinical inertia is an easy thing to do?

Scott Benner 1:03:10
No, I think I actually have a job because nobody knows how to do it,

Paul Hanson, RN, BSN, CDE 1:03:16
right and so, you know, I think there's a lot of variables that go into this, into your question. One of them, I do think, is clinical inertia and comfort. Unfortunately, you've got providers now that are being forced to see more patients with less time and improve their outcomes, etc, etc, and they have got incredible staff that has done all this incredible learning to be certified on all these different devices. And now there's even more and more devices that then, when you bring in something that is as unique and is different than insulin to carb, ratio, correction factor, basal adjustments, X, Y and Z, it causes a reset. And sometimes that reset can be hard, yeah. So my hope is that it will be more commonplace and in more people's, you know, bags, so to speak. I wonder if newer prescribers are going to be more apt to take it up because they've been given access to that in college as far as their training, etc, etc. I don't have the answer to that. What I do know is that the mankind team is is continues to do an incredible job, as far as you know, really promoting it and working with younger prescribers, between you and I, I think this is something that was game changing for me, and so I hope that there are providers that want to seek The education and the understanding about what it is, so that they can offer it proactively versus reactively, because that's what I am seeing now. It's more reactive versus proactive. I think that is a place that would be really nice for, you know, the product itself. What

Scott Benner 1:04:58
did you do for the COVID? Company. When you work there,

Paul Hanson, RN, BSN, CDE 1:05:01
I was a Territory Business Manager, and I also trained patients sales training for a while as as well. Okay, so

Scott Benner 1:05:07
then, what have you seen work when you talk to a clinician and when it doesn't work, what do you think stops them?

Paul Hanson, RN, BSN, CDE 1:05:13
There is no magic bullet. I think it's persistence. I think it's getting that prescriber that has a few cases that are very successful, and then that's something that you can build upon. The challenges is getting those few cases. Other instances are you have a patient that comes in and and from a grassroots standpoint, they're very motivated and they want to have the product. And you have a prescriber that has either been resistant or you just haven't been able to get into right? Because that's that is a thing with a lot of healthcare systems, a lot of times these reps that are working their butts off, they can't even get in to have this conversation, because the faculty is is is protected, because they're seeing patients, seeing more patients, less time happy to get better outcomes, and so they can't be educated about it. So a lot of times it's the grassroots effort too. And so being able to support a patient, or support that provider, when they finally call and say, Hey, I need to know what the heck this is, I don't have the silver bullet golden, you know, whatever answer for that, I think it's going to take time, and I do think that it's continuing to grow. I've seen that in the space that I worked in and with the teams that I worked with, that it is continuing to grow, so I'm very optimistic about it. What have you heard

Scott Benner 1:06:28
as far as pushback? What's the doctor said to you? Like, the thing I said, right? Like, I don't know. I don't want them inhaling something. I'm sure somebody said that to you, even though a ton of medications are inhaled, you know, it's not, not an uncommon way for us to deliver medication. Yeah, what else have you heard people say that that have been pushed back?

Paul Hanson, RN, BSN, CDE 1:06:45
It's, it's basically lung safety. And then how are you going to get them the dose multiple times? If you know they need to take a follow up dose, I can't even get them to dose once. Yeah. And the reality right is, is what happens if we just, if you presented it as an option, and it was an insulin that this patient could take, and it can meet them where they're at, which is, you know, three out of or two out of three meals a day. They're not able to dose right away, or not right away 20 minutes in advance. So

Scott Benner 1:07:14
is that argument like, look, there's not enough people who are very motivated to take good care of themselves. And the ones who are already have an insulin pump, it's an A ID or something. They don't need another thing. And the people you're trying to get me to help, I can't get them to do anything. I can't possibly get them to do this. Like, is that? That kind of apathy from the doctor

Paul Hanson, RN, BSN, CDE 1:07:34
gotta I've got to be careful with this. I think that the reality is, is the A I D s are doing such an incredible job, like truly, the A I D s are incredible that I wonder if the systems themselves have a program set up within where the driving force is to get them to what appears to be the gold standard, which is an A I D

Scott Benner 1:07:58
Yeah, their sales is, is got a better story than yours does kind of idea, yeah, yeah, yeah,

Paul Hanson, RN, BSN, CDE 1:08:03
yeah, yeah. And so if you, if you spent all these years getting a system set up where your job, your job, but your goal is to get people on something that is improving safety and outcomes and and all that, and then you have resistance to that, you know, it kind of puts a little kink in your armor? Yeah,

Scott Benner 1:08:21
the doctor could be like, Look, we just got to this. I'm not going to start on something else.

Paul Hanson, RN, BSN, CDE 1:08:25
Yeah, so it's a really good question, Scott, I wish I had the answer that's, I wonder if that's the cause,

Scott Benner 1:08:31
yeah, it's just different enough that it feels too different. Yeah, is what I think can be like a stumbling block. I think the breathing part is a stumbling block too, that you inhale it in. But overall, it's just, it's the different thing. Yeah, it is different. And you they just spent the last decade trying to explain to people insulin pumps using insulin like, I know, insults been around for a long time, but adoption of insulin pumps is not as great as you would imagine among people who have type one diabetes. You're correct, right? And so you're working, working, working. And how do you even get that work? It's because you've got a company trying to sell a pump. Like somebody went out on a limb and was like, Here, we'll make the damn pump. Now we got to sell it. We're out of business. So now it's their job to go out there and and, you know, extol the virtues. And then you you know, you get moving in that direction. Then another insult company comes along. Does it again, and before you know it, it becomes Kleenex to the doctor, and they're all pumps. And, you know, like now you're hearing it from five different perspectives. And then someone comes along, goes, Hi, you know, this man named, you know, Al came up with this, and he's gone now, and sanafi had it, and they seem to not care. And and then they go, that's a big company. Though, if they didn't care, maybe there's a reason. And then it goes, reverts back to the company, and they're out there, small company, trying to push it, it just, it seems like a tough slog to me, like, I mean, it just, but it doesn't make it not a viable option. And that's why I'm I continue to have people on to talk about it, because I, I do think I have the ability to, like, get the i. A story out there, and I'd like people to hear about it, you know? I mean, there was a time, Paul that people came to me and said, and I'm certainly not taking credit for this, but, you know, I am probably one of the places where that is heard more than other places that came out. And today, look, I'll put my kid on this loop thing, you know what I mean? And, and it's like I said, again, still. I mean, if loops on 20,000 people, that'd be amazing, like, Forget 20,000 people, and there's no way that it is. But let's say loops on 100,000 people, that's still a very small percentage of people living with diabetes. Now it's nowhere near that number. I I asked the internet. The internet says that as of 2023, 30,000 patients with type one or type two diabetes have been treated with a fresn. It doesn't say they're using it currently, but they've tried it. This number is based on patient exposure analysis conducted between 2015 and 2021. A fresn developed by mankind Corporation, is the only Ultra rapid acting blah, blah, so you don't even that's a long time. Yeah, 30,000 people, not a lot of people. And no, there's no way to say that they're all on it. But I've also had people come on here and act like a Fresa is, you know, if you come like you can't pry it out of my cold, dead hands, kind of a vibe. So like the people who love it, love it, they should be able to talk about it, you know,

Paul Hanson, RN, BSN, CDE 1:11:19
well. And this is, I think this is where you're working for the company. And again, I'm no longer working for the company. But I think if you are right, the goal is, is to have your providers presenting that as a viable option because of the uniqueness, versus not talking about it because of its differences in uniqueness, right? And so I'm going back to what we said earlier, Scott, we are blessed being a very different time than when I was eight years old, sitting on the doctor's table with Dr butthead. We've got all these incredible algorithms. We've got these CGMS that are continuing to push the envelope. And now for you know, gosh, it's technically a phrase that came out in FDA approved on June 27 of 2014 so it's been out, yeah, for for 10 years. We've got an insulin now that's it mimics physiological activity. If you think about that, Banting and Best have to be doing cart, food, cart, you know, cartwheels and backflips.

Scott Benner 1:12:24
Yeah? No, no, they. I mean, there's part of you that wonders if it's not just, like, you know, the whole VHS beta max idea. Like, you know, those beta people were probably just like, wait, what's, I don't understand. Ours works. It's better. The quality is better. The tape is smaller. You're going with VHS, why? Like, how doing the wrong thing. But I mean that can, that can happen also. It begs saying that when, when I went to a large Children's Hospital, you know, a well respected large Children's Hospital, with my little kid and I was looking for an insulin pump, for the first time I saw this a long time ago. I saw an Omnipod, and no one wanted to support it, and so, like, I I've told this story in the podcast, but I'll tell it to you because you don't know it likely. It was basically like, you know, you go in this room, it's a conference room, and they had tables everywhere, and there were pumps. Like they were like, just laid all over the place, like they were just selling these pumps. Like, you know, like, like, oh my god, people are excited. And I walked the whole room is a big room. There are a lot of people in there, over in this corner, like, this cut out corner of the room was this small folding table, and there was something on it. So I walked over to see what it was. But as I got closer to it, it realized it just looked like somebody tossed the thing on it, like it almost looked like somebody was walking to the table, got about eight feet from it, and were like, I don't feel like going the whole way and like, just pitched it off the wall, and it landed on the table. Okay? And you know what that was on that table? It was an Omnipod. And I went, I picked it up, I went over to one of the people working there. I said, Hey, I don't know anything about this, but my kids little, and there's no tubing on this that's really attractive to me. It's also it's self contained. So it occurs to me that if the company should upgrade it, it's not like they're going to make 1000 different versions of it, like, you'll probably keep getting the upgraded version like, at least more quickly than I would with something else. I had all these reasons why I thought it might be a good idea. And the woman looked at me. She looked at the pump. She goes, you don't want that. Now, this very, very long time ago, okay, like before, right before omnipotent had its foot in the door. You don't want that. I said, why not? And she gestured to my daughter, and she said, she's too thin for that. Now, time after that, I heard people who were approached the same way and told, Oh no, your kid's too chunky for that. You're too chunky, you're too thin, you're too old, you're too young, you're too this, you're too that. What the hell like? How can there be so many reasons why this thing's not gonna work for me? And I, of course, said, you and I probably have a lot in common. I said, Well, I'm gonna get it anyway, and then. As soon as, as soon as I, I said, I'm going to get it anyway. Then the scare tactics came about the insurance Well, if you buy, if you get this and you don't like it, you're stuck with it for four years and, like, this whole thing, right? Which, it's not even the case anymore, one way or the other, because it's, you know, it's not adorable pharmacy benefit now, but, but anyway, that I was then it was your daughter's the wrong size. You don't want that. You're then the scare tactic about the insurance. Then two years later, Paul, after one of my daughter's appointments, the doctor asked me to stay behind. Said, can Arden go out in the hallway with the nurse? And I talked to you for a second, I was like, I know I did something wrong. This is coming. And, I mean, she don't want to say it in front like, Dr butthead would have just said it in front of me. Yeah, at least, yeah, you had a good doc. So it's scary what's going to be said, but it turned out to be a nice thing. And she said, We want you to know that based on how well Arden is doing on Omnipod, we are going to start prescribing OmniPods to children out of this practice. And I said, okay, like, I was like, whatever. And but I said, let me ask you a question. Why did you try to stop me all this, you know, a couple years ago? And she just gets very still and quiet, and she says, well, in honesty, it was new, and we didn't know anything about it, so we didn't want to try to support something that we didn't understand. And I said, maybe that would have been the best thing to tell me back when I asked about it. Yeah, yeah.

Paul Hanson, RN, BSN, CDE 1:16:24
And Scott, I think you hit the nail on the head is there is, there is pride and expertise that we go to when we walk into the institutions and they have it period. However, when there is something new, they might not have that same level of expertise, and that can cause a little bit of discomfort. Yep. And how do they then, whomever respond when there is excitement about something that they don't have a lot of information about, it can cause discomfort. And I'm wondering if that's what you you saw

Scott Benner 1:17:00
there. That's exactly what I saw there, and it's what I'm guessing is going to happen to people who go into a doctor's office and say, Hey, I'd like to try that. Inhaled insulin. Yeah, there's this, there's that. It's that. Don't do that. It's gonna It's scary. Boo, yeah, I

Paul Hanson, RN, BSN, CDE 1:17:13
heard you. I heard you cough five years ago. You might not want to try it. You know, you're not gonna be

Scott Benner 1:17:17
able to breathe if you take that, right? You want to breathe. Breathing is important to you, doesn't it? Like the world keeps changing and and I get it's funny. I get scared. Sometimes I think that what seemed like common sense 10 years ago now seems like bashing to people. Sometimes I'm certainly not bashing anybody, but I think what you just said is right, is that people are still people. I this is my job to teach you this. If I don't understand it, how am I going? I don't have time to understand it. I can't learn about it. Blah, blah, blah, like, you know, maybe it's a control thing. May I want the control here. I don't want you know more than me. I don't know what it is people are. You know, humans are fallible and delicate, and they make all kinds of decisions for all kinds of reasons. But if you're making a decision about what you're managing your diabetes with based on something that's being said to you by, you know, a person who you think you're supposed to listen to. I still think it's on you to do your diligence and find out if that's correct or not. I agree. I agree because Paul did it, and it worked out well for him. I did it for my kid. And you know, you're all welcome. Who lived in the Philadelphia and surrounding areas back then and got an Omnipod like, but you know what I mean? Like, sometimes you just gotta push on.

Paul Hanson, RN, BSN, CDE 1:18:27
I agree. I agree with you. And reality is, everybody is going into those, you know, pump nights or visits with a different type of energy and different things on their plate that day. And it might not be a great day for them to go in with that chutzpah that say you had, and I had, for example, that's hard, and as a result, they might not push for that thing when it's new, and they might take the advice from somebody who doesn't have the understanding about the new thing. Yeah,

Scott Benner 1:18:55
you always have to wonder if you're being offered something, because the salesperson is pretty and knows where the better bagels are.

Paul Hanson, RN, BSN, CDE 1:19:03
I'm not a good looking man, so I can't really speak to that. Oh, Paul,

Scott Benner 1:19:06
you're, you see, you're at fault on this for as the thing I see what's going on. But, but no, seriously, like, if I, if I'm a, if I'm the lady at the front desk at the doctor's office, and it's my job to blah blah, blah, and sales people come in and I like that sales person better, then I might be more likely to say the thing that they're selling. When you ask a question, oh, what's the best insulin pump? Oh, you know, the best insulin pump is, it's the tandem. Why so? Well, the answer being because, you know, the bagels from the tandem person are really awesome. And the, you know, the Omnipod lady brings in donuts, and they always seem a little not fresh, and whatever it ends up being, I don't even know where the law lies anyway. By the way, 20 years ago, you could take a doctor on vacation to Hawaii and call it a work meeting. I don't think that's legal anymore. That's not, yeah, no, that's not. But I still think you can bring a bagel or a pen or something, or stand there and be delightful for 20 minutes. You know, I'm not a salesperson, but I think if. I was, I could rule the world. Paul, somebody's rolling into your doctor's office turning on the charm. You know, forget the bagels and everything else. The person at the front desk likes them. And then they go back to the doctor and they say, I think we ought to take a harder look at this. They made some compelling arguments. Who knows what those compelling arguments were? You don't

Paul Hanson, RN, BSN, CDE 1:20:16
know. You kind of just really provided a really good summary, which first and foremost is the world is changing in so many different ways, but within the diabetes space, for example, B, humans are fallible, right? And so, you know, based on whatever influences, they might not always be at their best when they're trying to help. So what that then means is, C, as people with diabetes, or families with diabetes that are really wanting to learn the most about the options out there. The hope is, is that with all the information out there, that information is easily found, and then when you're in front of that team, you can have an audience to have a really good conversation and make the best you know choice for yourself. Yeah,

Scott Benner 1:21:00
I just don't care. I'm not just talking about a fresn, honestly. Like, if you want a GLP, go fight for a GLP. If, you know, if you're in there and you think I want an Omnipod five, and they're trying to give me a T slim x2 argue with them. If you're trying to get a T slim and they're trying to give you an Omnipod five, argue with them. Like, you know what I mean? Like, geez, if you're in Minnesota, they're gonna offer you a Medtronic, I guarantee you, like, you know what I mean? So, like, Paul's laughing. He knows the business a little bit. Yeah, stick up for yourself a little bit. And when somebody tells you no, don't just say, Okay, say, why? And if that reason doesn't make sense to you, then you got a little more work to do.

Paul Hanson, RN, BSN, CDE 1:21:35
I agree. And, and you can decide if you're going to keep this in here or not. But you mentioned, you know, the GOP ones. You're not going to be surprised about this at all. But as a type one, I fought like the dickens to get onto a GOP one IP combo, because I started to, as I got older, started to have a little bit of resistance, and I was not used to that. And this is after, you know, fifth knee surgery. It wasn't active, put on weight, all the all the things, right? And they just like, Well, no, you can't, because it's not for type one. I was like, might speak to somebody who's medical versus somebody who's just reading a check the box type thing, because type one diabetes is much more than just your beta cells being affected and like this is nonsense. Long story short, I have an incredible endocrinologist who helped go to battle with me, is able to help me get that I don't use it with the regularity of a weekly dosing or anything like that, but what it's done for me is it's helped with that sensitivity, and it's pretty incredible. And I am interested to see what's going to happen over the next, honestly, five years or so with, yeah, with the type one space and GLP ones,

Scott Benner 1:22:47
I've done a ton of content already. Listen, I got it for my daughter. I got it covered, by the way, you argue enough, you can do anything that's for all you're out there. It's tough because the lowest dose is, is too much for her. It's so robs her of her, like, hunger, that it's just, it's too much. So we were, you know, working with, like, trying different doses, different time frames, but, you know, like, and then we actually have, we don't talk about this very much. Arden has a pretty significant needle phobia that comes and goes once in a while, and so that's been a problem. I actually just got her a sample of rebellious to try that, to see if maybe we can make make some impact with that. But when she's on the GOP, her blood sugars are legit stable, and it is difficult to get her blood sugar over 140 when she eats. Isn't that crazy? Yeah, that's awesome. And so I am nativity is amazing. Yeah, I am going to figure it out for but I also don't want her walking around not hungry. I don't want her like, you know what I mean, like, I'm not looking for that, so we're working it out. But, yeah, no, I'll leave it in here. I have a ton of content about GLP. I'm a I'm a proponent. So, yeah, no, all right, Paul, I'm going to let you go, because if weeks goes any longer, my editor is going to charge me extra.

Paul Hanson, RN, BSN, CDE 1:24:00
It sounds good. Hey, it's been so great to connect again. I'm glad I didn't have to stalk you at the bathroom. It would have gotten a little awkward, actually. So I

Scott Benner 1:24:09
mean, here at the end, if you wanted me to go pee to make you feel better about it, I probably could go. I think we'll

Paul Hanson, RN, BSN, CDE 1:24:13
just pass on that.

Scott Benner 1:24:16
Thank you. No, no, it's my pleasure. You're really great. I'm glad. Hey, who helped me get you, Steven, it was Dave Akers. Dave Akers, oh, okay, well, oh, and Stephen went to Dave. Dave, go into you. That's right. Well, thank you everybody who behind the scenes puts in this kind of effort to make sure we talk to good people on the podcast. So, yeah, thank you so much. Hold on one second for me, Paul, I did a good job, right? We covered it all. Yeah,

Paul Hanson, RN, BSN, CDE 1:24:40
I think it was a great it was a conversation. It's organic, which is, again, one of the reasons why I listen to you. It's organic. I appreciate

Scott Benner 1:24:46
it. All right. Hold one second for me. Man,

can you name the only CGM that has only one sensor placement and one. Warm up period every year. Think about it. It doesn't matter if you can I can ever sense 365 is sponsoring this episode of The Juicebox Podcast, ever since cgm.com/juice box, a year is a long time. A huge thanks to us med for sponsoring this episode of the juice box podcast. Don't forget us, med.com/juice, box. This is where we get our diabetes supplies from. You can as well use the link or call 888-721-1514, use the link or call the number get your free benefits check so that you can start getting your diabetes supplies the way we do from us. Med, 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, wrongway recording.com, you.