Formula Fact Vs Fiction - Part 2

We're about a week out, and Child2 is doing great with his surgery. Now I have time to return to the questions that I regularly get asked about formula.

What about Soy?
Nutrionially speaking, soy formula is pretty much the equivalent milk based formulas. People used to switch to soy if their infant is spitting up alot or they were concerned about milk protein allergy - which can result in cranky babies with blood in their poop. An allergic baby is reacting to the milk proteins which can come from the formula or via breastmilk if mom eats dairy. If the child didn't have milk protein allergy while breastfeeding, she/he doesn't need soy. Also, milk protein allergy often is cross reactive with soy so you aren't helped at all by switching to soy. I have met some hardcore breastfeeders who cut dairy and soy of of their diet for months with the hope their child would outgrow the allergy. (which they often do)


What about medicinal use of soy formula?
Soy absolutely has a place for certain medical conditions like a rare disorder called galactosemia - can't digest galactose - or parents who have ethical concerns with using animal derived products. On the flip side, premature babies are NEVER fed standard soy formula because it can prevent absorption of calcium and phosphorous - giving a child ricketts!


Should I switch formulas because my newborn is lactose intolerant?
No. Your infant is NOT lactose intolerant. Infants cannot be lactose intolerant; all infants are born with enzymes to break down lactose because it is a main component of breastmilk. Lactose intolerance refers to the loss of that lactose breaking up enzyme which occurs at about about a year of age. Many Caucasian populations keep a much higher concentration of that enzyme after 1 year old. Other ethnic groups do not keep so much. Truthfully, most lactose intolerant people have enough of the enzymes remaining that they can eat small amounts of dairy. If this describes you, four pieces of extra-cheese pizza or an extra large Dairy Queen Blizzard are not good options without enzyme replacement (lactaid) - though one small piece or a small cone may be doable.

What about Gentle/Sensitive/Low iron?
Welcome to another marketing ploy. This plays on parents belief that their child is lactose intolerant and the gentle formulas are 'lactose free.' As already discussed, not really the issue. It may give a parent a sense of control that they are trading formulas, but their child's spitting up/irritability will probably improve with time and or technique. These formulas still contain milk protein so if the child has milk protein allergy it won't make a difference.

Most pediatricians will roll their eyes outside of the exam room and let people change formulas because if the parent perceives something relatively harmless to be true, it's not worth the battle. For example, refusing vaccines is very harmful and needs to have time spent on that issue. Changing from a nutritionally sound standard formula to a nutritionally sound 'senstive' formula is safe and fighting it is generally not a good use of time for the doctor.

Low iron formula is not marketed in the US because it is DANGEROUS! The best iron bioavailability (gut absorbing) food is human milk. Human milk has a fraction of the amount of iron in commercial formula, but it is absorbed so well iron supplementation is not necessary unless there is an additional health problem. Commercial formula's iron is not absorbed as well and must have more iron in it to let babies reach a safe level. If you have located low iron formula, it was manufactured in a foreign country, and you are facing a HUGE danger of feeding your child a questionable, potentially non-safety controlled substance that could easily lead your infant to becoming severely anemic.

What about Nutramigen/Alimentum/Elecare/Neocate?
These formulas fall into the 'elemental/amino acid' based formulas. Each of these is an expensive, semi-digested formula for infants with major health issues that cannot safely digest normal formula or breastmilk. They actually smell like they are partially digested and taste horrible too. The closer you get to elemental (Neocate) the nastier it tastes/smells. No one should be using these formulas without the blessing of their doctor. Some of the things that would make a physican consider these formulas include severe reflux, consistent weight loss, failure to thrive, genetic disorders, digestive surgery, and cancer treatments.



My baby was premature - what about him/her?
It's standard practice in the United States to give infants with normal digestive systems milk-based higher nutrient higher calorie formula. Normal formula/breast milk is 20 calories per ounce. Neosure/Enfasure 22 are 22 calorie formulas with a different protein/iron/fat ratio than standard formulas because premature infants have different needs for growth and weight gain. The powdered formula can also be added to pumped breastmilk to increase the calories content to 22 calories. Preterm infants generally stay on these formulas at least six months with some adjustments for weight gain and gestational age. Infants with severe digestive system problems/surgeries will be put on special specific formula diets with consultation of pediatric gastroenterology.

Long story short, it is totally fine to buy generic formula because it is almost identical to name brands. Your child only needs formula till one year of age and the various stages and additives are generally marketing ploys.

Saving health dollars with paperwork

Just to follow up on my bill paying section, I wanted to give a little advice about dealing with insurance companies since Child2 is about to have outpatient surgery this week. (That belly button thing I posted about a while ago)

1) Get a referral: If you go to your primary care physician (PCP) for anything and you anticipate the need to see a specialist, ask for a referral AND get a copy of it. So if you are visiting your PCP to get a blood pressure check and you were thinking about seeing a dermatologist for a skin check sometime, physical therapy for nagging back pain, or plastic surgeon for skin tag removal, etc - ASK FOR A REFERRAL. It costs the doctor nothing except a piece of paper. It's great if you have a specific physician in mind, but if not, just get it on a prescription pad and take it with you.

2) Touch base with your insurance company: patiently wait on the phone to talk to a human being and ask if they cover X service and what the copay will be. Ask if there are limits to how much they cover and if you will be charged separately for hospital, lab, and office charges. Mention that you have a referral, even if you don't officially need one. Be nice; we'll discuss that in a minute.

3) Confirm your appointment and referral: When you set up your appointment with a specialist, make sure they have your referral on file. If they don't, give them your PCP's office information and bring your copy of the referral to the appointment. Everyone's office is interested in getting paid.

4) Review your bill and your insurance statements: If you get approved for a specialist or procedure, you should receive notice that you can see specialist Z for X number of visits. When you get your bill from the physician/hospital/lab (or all 3 separate bills), make sure insurance covered your visit. If you need to, ask for an itemized bill. Then call your insurance company and discuss what they did and did not cover. BE NICE. They get yelled at all day by irate people. If you are nice, they will be willing to refile claims for you, resubmit them, contact the doctor's office, or take it up with their supervisor.

5) Record name, date, and activity: Get the name and number of every person you talk to. Write it directly on the bill, '11/20/12 Talked to Sherry in customer services, will forward info to her supervisor and hear back in 30 days. 777-664-9041' Insurance companies and doctors office employees know each other and can confirm that type of information. Insurance companies generally will have an electronic record of this type of correspondence and will look toward that date you tell them in followup. It will also keep them from turning your over to collections.

6) Keep your records together: Come up with some type of filing system that keeps your medical bills in once place. I personally have a file on top of my desk that I keep the current projects in. I put sticky notes that say 'pending' on the ones that are in process. I move them to our general file system the main portions once they are resolved and shred the ones that were minor correspondence or extra copies.

Now for my true story. I was able to save somewhere in the range of $700 for medical bills during my pregnancy by calling and talking to hospitals, insurance offices, and doctors offices. I was in a car accident and had to be seen in the ER. Since I was pregnant, once they all agreed I didn't have a broken neck, they sent me up to OB floor. I was later asked to pay for the copay for the ER and then 'out of network' OB office costs because that was how the hospital charged for OB services. I was able to successfully get my out of network fees waived because it was an emergency visit and I didn't get to 'select' which OB was on call.

Furthermore, I had some bleeding at the start of my pregnancy and was referred to the high risk specialists. I was also going to VBAC, so when everything was okay, the high risk specialists kept me on as a patient even though I was not high risk at that point. I was just receiving normal care from their office. My insurance company would usually pay $6,000 for my entire pregnancy care and I'd be responsible for $300 as a bulk payment. However, since I kept seeing the specialists, I was getting extra bills for $50 after every visit. It took a bunch of phone calls, but I got the office to re-code for almost all of the visits and I only paid an extra $25.

Keep in mind, there was alot of waiting on the phone to get all of this done over a period of weeks, but it was WAY cheaper than actually paying all of those bills.

Better Bill Pay in 5 steps

We just had a bit of a financially harrowing incident over a bill which has led me to create "Better Bill Pay in 5 Steps" so it won't happen to you. Anyone can accomplish this with 1 or 2 hours of work.

1) Electronic bill pay: Examine all the bills you're paying via checks or mail. Can it be faxed? Can it be paid electronically? Can you place it on autopay, and your bank mails the check for free? Are your student loans on autopay? You should get a 0.25% interest rate discount if you place them on automatic electronic payment for government loans. 250K loans at 6.8% over 30 years with a monthly $1630 payment comes to a total savings $40,000 and 27 fewer months.

2) Personal bill pay: Are there any bills that you can pay in person? This is much more likely to be effective at a local organization like a church, synagogue, landlord, or small doctor/dentist office than a larger organization that has its billing off-site/out of state. Combine it with a grocery trip and stop buying stamps.

3) Confirm your address: Make sure that any correspondence that needs to reach you has an appropriate forwarding address available. Bizarrely, the post office charges to do address changes online so ask for the paper forms. Then fill them out for any address you have moved for the last 5 years. Mail forwarding only works for one year and then needs to be renewed.

4) Consolidate/phase out your email accounts: If you have moved jobs/graduated school, it is very possible that your email address is still receiving mail. I recommend getting a dignified name of some type on gmail and filtering all your email into that. Whatever you do; if an email is going to be shut down or essentially unused, set up the auto-email informing mailers of your new contact information.

5) Know how to access all of your accounts electronically and check them weekly: This way you will know if any strange chargers appear or if your scheduled electronic payment suddenly stops. Even better, be familiar with when your electronic payments are scheduled versus when you get paid to know when you can put aside extra money or make the extra payment.
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Now onto our story. Our out-of-state condo is undergoing a re-finance that will remove that pesky first-time homebuyer residency requirement. Our renter pays into the local account and the mortgage and condo association dues came out of that account on autopayment. Unfortunately, the condo association moved to a new management company last year, but we were never informed because they sent that information to the condo itself (haven't lived there in 4 years) and HubbyJD's law school email account. The old management company forwarded our checks to the new company every once in a while, when they felt like it. Then they just stopped and the checks expired so the money was credited back to our account. HubbyJD finally checked that account and noticed the credits.

He immediately followed up on the electronic trail in his old email and found we about to have a lien placed on the condo we were trying to re-fi! I had also made an extra $1.8K loan payment THE DAY BEFORE. He contacted the mortgage companies lawyer and straightened things out - provided we pay everything immediately. Fortunately I knew exactly where we were in our monthly banking cycle to come up with an extra $1.5K that afternoon. Since I run the household finances, I immediately enacted steps 1-5.

Formula Facts Versus Fiction - Part 1

As you know, JaneMD loves Part 1 and 2's. So here comes another one on formula . . . particularly since some people have expressed some interest in more about newborn care/prices

Real conversation in the outpatient office:

Patient's Mom: My baby spit up alot since I changed to step 1 formula at 2 months. So we tried the sensitive formula; she was still gassy. I tried soy for a few weeks and she seemed better, but after she had a big spit up, I went out and bought some Alimentum now that she's five months.  She doesn't like it very much, but she's stopped spitting up. I know she's lactose intolerant.
Me: How many ounces were you feeding her at a time when she was 2 months old?
Patient's Mom: Eight
Me: How many ounces does she take now at a time?
Patient's Mom: Six or seven

This mom has fallen into a trap that I think of as 'The Great Formula Lie.' This mom had no idea she was taken in by advertising and false claims. She spent alot of money and time switching formulas for spitting up when if she had not overfed her two month old, took some precautions like sitting her baby upright after feeding, or asked her doctor, she very likely would have it avoided completely. 

So in this two parter, I will discuss major lies - I mean 'selling points' that marketing trying to use on you.

#1 - Stepwise formula:
Ah, Enfamil. Even though I was a solid breastfeeding mother for the first 7 months of life, you continued to send me formula samples. Your advertisements said things like 'I am not a baby, I am an infant.' All ridiculous lies. I appreciate that you sent me a sample of Newborn and Step 1 once a month, though because it was free.

I once set those Newborn and Step 1 cans next to each other and examined the ingrediates and nutrients. Essentially exactly identical. The ONLY difference was Newborn had 75 units of Vitamin D and Step 1 had 60 units per 5 ounces. That is all. The entire difference. Both claimed to have prebiotics, both claimed to have DHA and ARA. 

Well, Vitamin D must make a difference, right? Not really. Your child is recommended after the age of 3 months, if breastfeeding, to get 400 IU of Vitamin D daily. Step 1 formula would require drinking of 33 ounces and Newborn formula would require 27 ounces a day. The newborn formula claims to be used 0-3 months, and the step 1 is 0-12 months. Except you don't need vitamin D supplement until 3 months of age and then you don't really need the newborn formula, or you could buy all newborn formula since the difference is so small.

I grabbed Walmart formula and guess what - it is completely identical to Step 1 Enfamil! Everything is the same - including its claims for DHA, ARA, and prebiotics. This is because the US FDA controls what is in formula and it must meet a certain requirement so all formulas, Enfamil, Similac, any generic are nutritionally, for all intents and purposes, the SAME. In fact, there are no studies that show outcome (IQ, growth, and so forth) over any type of formula in a normal child. These claims are like stating that using a 'Graco' carseat over a 'Costco' carseat will make your child more likely to graduate college.

Enfamil also started sending us 'Enfagrow' stage 2 powder for kids older than 1 year old. However, there is no reason to be giving formula to a normal child after he/she turns 1. The label claims to be much better than whole milk - though hilariously the first ingredient is whole milk. If you are still feeding your child formula at a year, you are failing introducting new foods.  Your child should be taking up to 24 ounces of milk a day and all the rest of his/her nutrition should be from FOOD. Not formula! For much cheaper, feel free to feed your child whole milk and give them a chewable vitamin with iron once a day. Many kids can be picky eaters, and this is just to bolster any nutritient they may be missing.

#2 - Marketing through fear:
The label on the advertisement for Enfagrow reads "Enfagrow Preminum Toddler or Milk? **You decide**" (It really said that.)
Translation: You are failing your child if you do not buy this formula. Even better, they have a random well groomed woman in a white coat holding her glasses. I assume, since she is unlabeled, not wearing an ID, and testifying her love of Enfamil, she is a model portraying your friendly pediatrician. (Similac is has similar ads; I just happen have the advertisement on hand)

Look at the claims on a typical can of formula. You'll see they claim improved brain growth, size increase, and all sorts of other things. As I said, since formula is controlled through the FDA, all of the differences between the standard formulas are going to be minimal. You can't fail on any of them. We did all Walmart formula for the first child and are currently using Enfamil because I get it free as a hospital employee.

Don't be confused - there is nothing wrong with using formula. Not everyone wants or needs to breastfeed and that is OK. Just don't fall for the marketing that tries to convince you one is better than the other.

To be continued in Part 2 next week where I'll discuss various types of formula that are out there.

Glorious resident lifestyle continued

It took a little longer than planned to get my post up because of the Jewish Holidays. The High Holidays were upon us and had all sorts of no computer rules. In order - Rosh Hashana: repent, eat big meals, Yom Kippor: repent, don't eat at all, and Sukkot: celebrate by eating all meals in a hut with no roof for a week - hence today's photo of 'hospital sukkah'.

Returning to the actual planned content of my post: In Glorious Resident Lifestyle part 1, I established that I worked hard and was paid badly as a resident. So what exactly did I do during my 30 hours of call?

My typical call day as a 1st year pediatric resident:
6am: arrive and get sign out about events that happened on my patients overnight.
6:30-8am: examine and talk to each patient. Update patient record (daily notes) on 3-10 patients depending on census
8am-9a: attend educational conference if possible, continue to write patient notes.
9a-12noon: round on all patients with whole team - 12 to 30 patients. Leave group to perform procedures - deliveries/lumbar punctures/cpr/central lines
12noon-1pm: educational lecture. take sign-out from person who was just awake 30 hours.
1pm - 5pm: complete patient work, perform procedures, admit new patients, sign out all other team members
5pm-6am: continue patient work for 12-30+ patients, perform procedures, admit new patients, 10pm nursing/patient check. Possibly sleep in call room if kids stable. Possibly sleep at desk outside of unstable kids room. Possibly sleep not at all.
6am: sign out other patients to rest of team.
6:30am-8am: see all patients, write all notes
8am: educational lecture, try to stay awake
9am-noon: round on patients again, try to finish all work to sign out by noon at 30 hour limit.
noon - 6pm: sleep
6pm: HubbyLawStudent arrives home. Based on business of call night and cleanliness of apartment,  may or may not have an arguement.
9-10pm: go to bed because it starts again at 6am

Staying awake for 30 hours was the worst and hardest part. I was usually pretty good until about hour 20-22, and then my productivity died horribly. Sure, I had a call room that I could possibly have slept, in theory. Winter is the worst because of RSV season leads to a huge number of hypoxic - not getting enough oxygen - infants. July is hard because the new interns need alot of attention and guidance. June is probably the least busy pediatric month, everyone has the most experience and kids are out of school avoiding germs.

That was as an intern. As a senior resident, you got to do 12 hour shifts instead of calls - except you would be scheduled for 13 shifts in a row with 12 hours off in between each one. With the new 60 hour work week, that averages out to 5 x 12 hour shifts per week. Nurses, btw, work 15 x 12 hour shifts over a full month which is like 3.5 per week. They would also get paid overtime or night-shift differential, which residents do not.

If you thought that sounded rough, imagine being a surgical resident. They have schedules like that for 5 or 6 years. You can pretty much cut out my lunch or rounding time and replace it with 'surgery' for hours on end. OB? Replace lunch or lecture with 'wait for babies to be born/c-sections' which they do for 4 years. Pediatrics, family medicine, ER, and internal medicine (among others) are considered pampered lightweights.

 This says nothing about what it was like emotionally to be a resident. You were exhausted, you were in charge of training the other interns and medical students. You had to achieve a certain number of procedures to graduate and pass various national exams. You had to deal with blood, puke, pee, poop, and pus. You were sometimes belittled or yelled at by attendings, nurses, other residents, fellows, and parents. Whole blogs are dedicated to how alone and powerless you often felt. It's not a suprise that arguing with my spouse got mentioned as part of my post call ritual.

As an attending hospitalist, I have a WAY better schedule. I work around 50 hours a week, with some call at a lower risk facility. I also get paid twice as much as a resident, which is still considered pretty low, even for a lower paid specialty like pediatrics. I could have added 20K to my starting salary if I had joined a group practice or wanted to work more.

(I'm lucky because pediatric subspecialists are generally overworked and understaffed because they take 3 more years to educate after residency. There are whole metropolitan areas where there is ONE pediatric geneticist for 2 million people. That means they are on call 365.25 days/year, can't take vacations because if a kid with adrenoleukodystrophy gets a stomach virus, they have to be available to manage the correct fluids and treatment.)

If you want a TV representation of what residency is like, I would recommend Scrubs as your look into our lives.

To end on a funny Scrubs-esque note, here are 10 Things that I actually heard during Sign-out.
Be warned - partially funny and partially cynical. Remember, these are from people who were awake for 30 hours.

1. That asthmatic patient, did you forget to tell me he was missing two limbs?
2. To the Jewish doctor - This Orthodox Jewish family has all these weird rules on Saturdays. Do I need a social work consult? (No)
3. We'll just say this family is pretty 'concrete.'
4. This patient weighs about three Kentucky Fried Units.  (450 pounds)
5. Her/his mom handed me a book on the vegan/gluten/dairy/sugar/preservative-free/all natural/organic diet she uses on her child.  We're treating him/her for malnutrition.
6. We had a Soap opera baby today. The woman didn't actually have a child but have been lying about it for three years and now theoretical father wanted to see imaginary child.
7. I could tell you all twenty meds the specialist put them on, but they haven't taken any for three years.
8. Child is fine; mom left to go use cocaine. CPS is waiting for her when she gets back.
9. This child was stabbed in the vagina by a rhino. Not a real rhino, a rhino statue at the museum.
10. Don't open the security bed, even if the delusional psychotic teenager seems better. He just beat the cr@p out of his mom, and it took 4 security guards to tackle him on his last escape attempt.

Glorious resident lifestyle of the not rich or famous

You are sitting in the pediatric ER with your child that may or may not have appendicitis. First, you saw the medical student who talked to you for 30 minutes. Then you saw a tired looking pediatric resident who talked to you about the exact same thing for 15 minutes. Then you saw a much more awake pediatric ER attending physician who talked to you for five minutes, agreed to admit your child, and get a surgical consult. 30 minutes later, the surgery resident sleepwalks in, presses on your child's belly and mumbles that he's getting a CT of the abdomen with a blood draw, and wanders away.

D@mn, you've been here 3 hours and what the heck? Why did those residents look so tired and am I seriously expected to leave them in charge of my child?

Before discussing the actual resident lifestyle, let's lead with resident compensation. The federal government pays teaching hospitals $200,000 to train each resident per year. The resident is actually paid, pre tax, in the $40-50K range. Med students pay $40-50K for the privilege of training.

During my residency, I had an 80 hour work week and no call lasting more than 30 hours. New regulations recently moved the limit to a 60 hour work week, no first year call over 18 hours, and no later year calls more than 24 hours per the schedule. Some leeway is given for emergencies and unstable patients.

How did that translate into actual money and hours? Well, I made $40k my intern year. I worked 80 hours a week while on service, did not have any holidays off, got three weeks of call free vacation and one call free month. That averaged out to 70 hours a week for 49 weeks - 3430 hours a year. Taxes/insurance took about 20% of my salary, no 401K for such lowly peons. That led to $32K over 3420 hours - $9.35/hour. That is similar to a McDonald's manager, except a typical resident is 27 and already completed 4 years of college and 4 years of medical school.

Oh, I got two $5 coupons for hospital cafeteria food for each call night. An 80 hour work week required call every 4th night, which I got to do for 45 weeks of the year. 45weeks x 7 days/4 days is 79 calls x $10 = $790 in 'food' perks. Yes, just like the McDonald's manager.

How anyone can pay off their $150K+ in loans on a salary of $9.35/hr and $80/month in 'food' perks just boggles the mind. Does anyone have that much self control when working 80 hours a week? If you were wondering, the 60 hour work week essentially will remove call free months for everyone, so do the same calculation with 60 hours - $10.88/hr with less food perks.

So what was my personal resident financial lifestyle like? I lived across from the hospital, so I didn't ahve a car. I was supporting first 2, then 2.5, and then 3 people on my salary alone. (Remember HubbyJD was originally HubbyLawStudent?). I packed my own lunches and used my cafeteria cards to buy food that I took home. Keeping kosher, I was able to take milk, cereal, fruit, hot chocolate home with the plastic silverware in $5 increments every 4 days.

Stay tuned for more glorious residency lifestyle next week . . .

BJ's and I agreed to see other people

If you didn't know, BJ's offered their 3 month trial membership this summer. With my family of 4, I was not certain I would shop there often enough to make it worthwhile to buy a membership. I assumed that the 19 Kids and counting people used BJ's . . .

In my 3 month trial, I went to BJ's 4 times. The first two times I bought the objects I was scouting to see if I'd like them in bulk. On my 3rd visit, like a good scientist, I took my shopping list from Walmart to BJ's, recorded all the prices on similar brands, and then put it in a spreadsheet to compare my savings. I also examined which items and brands BJ's vs Walmart vs specialty grocery store carried. The last visit was the big purchase when I spent $350.

The good: I was able to buy challah (Jewish bread), kosher salami, and stuffed grape leaves for rock bottom prices I could not find anywhere else. I went a little wild and bought ALL of their two loaves of challah for $5 compared to my local grocery stores $7 per loaf. Similar issue with the salami - I bought all of it they had in stock and put 20 loaves of bread and 30 12oz salami in my fridge. I bought bulk plasticware, nuts, cups, and nice paper plates. I had enough storage space that I may not have to do that again for another year.

The so-so: I was able to find peanut butter $0.50 cheaper per container than Walmart. Not too exciting. I was underwhelmed by their bulk oreos, frozen vegetables, and Mrs. T's Pierogies. I found deodarant cheaper by $0.25 a container, if I didn't care about the brand. Morning Star Farms products cost almost exactly the same since Walmart started selling the 8 pack burgers.

The bad: CFLs were $0.60 more expensive per bulb than at Walmart! BJ's bulk diapers were more expensive than Walmart bulk diapers. Black beans, chick peas, and lima beans were $0.10 per can more expensive than Walmart-even though they come in six packs. Bagged sandwich bread was not cheaper than Walmart. Bulk fresh fruit - apples, oranges - were all cheaper at Walmart. Whole wheat nutrigrain waffles and egg beaters were the exact same price. Walmart brand protein bars were cheaper than the namebrand ones sold at BJs. They had very narrow brand selection and few whole-grain choices.

I also noticed how tempting it was to 'overbuy' things. Look, paper towels in bulk! I should buy those . . . except we use rags instead of paper towels and just wash them. There were tons of products I almost bought and then remembered that I did not miss the object before I saw it at BJs and it didn't have a place in my house. I think having so much on hand would tempt me to make larger meals and consume more items. For example, you make a tray of brownies for dessert on Monday (bought in the Duncan Hines brownie mix 4 pack) and have half left over - which you end up snacking on all week and put on some weight. Or you can use spend cut the recipe in half of the 5-minute Chocolate Mug Cake, even cheaper.

Quick, buy 30lbs of whole wheat flour . . . nevermind, don't need flour now that I froze all that bread . . .

Once I stocked up on my specialty kosher items, the difference in cost between what I regularly buy at Walmart and BJ's wasn't worth the temptation to overbuy. I am hoping that the next few months grocery bills will be lower because of this, but that remains to be seen. Should I ever need bulk purchasing of those items, I have some friends who shop there regularly and are happy to buy for me.