Wednesday, November 28, 2012

Know Your Insurance Formulary

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When kids with a chronic illness (migraines, asthma, ADHD, acne) need a first-time prescription, I often ask the parents to look at their formulary first. This upsets some parents because they want to start something today, but I refuse to play the phone tag game for the next week.

What do I mean?

Most diseases have more than one medication that can be used to treat the condition. Many of these medicines are very expensive, and insurance companies put them in various tiers depending on how much they pay for the medicine.  The more they are contracted to pay, the higher the tier, resulting in a higher copay for the consumer. This varies from company to company, so what someone with a prescription plan from Company A has different costs than someone with a plan from Company B.  Even different plans within company A vary.  High deductible plans add in even more confusion because your cost depends on how much you've already spent.

I saw a formulary for one company recently that the medicine was generic tier for those under 18 years, but over 19 years it needs a prior authorization. Huh? The condition doesn't change with the birthday. The medicine is approved for both age groups. Why they have that prior authorization requirement is a puzzle to me.

I simply can't keep all the plans straight. Ideally electronic records would link to each insurance plan's formulary and let us know immediately how much a prescription will cost, but they don't.  Even pharmacies can't give the cost until they "run it through".  There are simply too many insurance plans.

So if you think you will need a long term prescription for a long term problem, I simply ask that you do your homework first. The insurance company won't tell me what your plan says. You must ask.  When we know the formulary, we can discuss the best option to begin treatment.  When 2 medicines have equal risks and benefits for a condition, we will choose the least expensive. If the lesser expensive options don't work, we may end up on a higher cost medicine. At that point other things have been tried and the cost is more acceptable.

Without the formulary, what tends to happen is I write for Drug A. When the parent goes to the pharmacy to pick it up, it is too much money, so they call use to change. Of course they don't know what to change to, so I change to Drug B.  Same story.  Turns out, it will be Drug E that is the lowest tier. Parents are frustrated with me for not giving the "right" one, but I am blind. Drug A was cheapest on the last plan I wrote a script for. Who knew yours is different?  This leads to too many trips to the pharmacy and phone calls back and forth. Everyone is frustrated and time is lost. It is faster to spend some time in advance finding out what to try first!  Please.

Believe me, this is frustrating for all of us. I wrote about my personal experience with formularies in Health Insurance Woes.  As an update to that, we are now using a mail order pharmacy. It is still much more than our last plan, but better than local pharmacies.

Saturday, November 17, 2012

Is an apple a good bedtime treat?

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As parents we try to get as many fruits and vegetables in our kids as they will take, so when Junior asks for a bedtime snack, it is tempting to allow a piece of fruit. Sounds healthy, right?  Surely better than ice cream...

An apple is healthy and can be a great part of a healthy snack, but kids (and adults) shouldn't have a high carbohydrate snack before bed without some protein and / or fat.


When we eat, our body senses the increase in blood sugar and sends out insulin to store the sugar in cells for future energy. An apple (or other fruit) is high in carbohydrates (sugar) and low in fat and protein. Sugars and can be quickly stored, lowering the blood sugar pretty fast unless there is fat or protein to stabilize it.

Fats and proteins are more complex to digest.  They must first be converted into smaller molecules before insulin can store the food for energy.  This allows a more gradual fall of the blood sugar.

Why is this important at bedtime?

We always have some sugar in our blood, ideally 70-100 mg/dl, but rising after eating and falling when fasting (not eating).  Normal sugar levels give our cells energy for all they need to do. We go for many hours without eating again when we sleep all night. If the insulin level is still high after storing all the easy to store carbohydrates but there aren't more molecules from the breakdown of protein or fat around to start storing, the insulin lowers the normal blood sugar to unsafe levels.  This is especially dangerous at night because one early sign that the blood sugar is too low is tiredness, which is unnoticed when asleep.

Diabetics should be especially aware of this response because their body does not regulate insulin normally, and they can suffer from severe low sugar if too much insulin is given without the proper balance of nutrients.

It would be extremely uncommon for a person with normal sugar management to have serious consequences of low blood sugar (such as coma or seizures) from this apple before bed, but without a good sugar level, the body will not get the most benefits of sleep: restoration of the body and growth in children.

So what's my recommendation for that bedtime snack? Go ahead and give that apple-- with a glass of milk, yogurt, peanut butter, cheese, or other food with protein.

And ice cream isn't all that bad as far as a snack that won't lower blood sugar too much... it just has less nutritional value.  So as a fun treat when kids are eating enough fruits and veggies the rest of the day and have gotten exercise and not an overabundance of empty calories, it's okay to have an ice cream once in awhile.  After all, it's made from milk, so not all bad!

Which reminds me of this great Bill Cosby clip: Chocolate Cake  (Who says we can't have a little fun when talking nutrition?)

Saturday, November 3, 2012

Taste a Bite Without a Fight

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Here's another blog inspired by a facebook question:

Megan Brower Lynberg My 2.5 year old son is super picky and I swear he looks at certain foods and decides not to eat them. I know most parents have the try it rule, or just one bite, but we can't even get him to do that most times. Any suggestions on how to implement that? Or should we just let it go and know that for the most part he gets a balanced diet and hopefully he'll branch out as he gets older?

Picky eating is synonymous with most toddlers and school aged kids. I smile inwardly when parents boast that their one year old will eat anything, unlike "other kids" who are picky, as if the other parents did something wrong.

It is between 15 months and 3 years that kids who used to eat anything go through phases of pickiness. I say phases, because sometimes it is a favorite food one week, only to be "yuck" the next week.  I knew this when my kids were young, so I took pictures of my toddlers devouring things like broccoli, so I could show them later that they did, in fact, love it.  (It didn't help.)

Overall the two biggest food groups kids dislike, vegetables and meats, are two of the most nutritious, so parents fret about how to get the nutrition in.  My general advice: parents decide what foods are offered, kids decide how much they eat.

My kids learned "Taste a bite without a fight" at daycare. Why silly rhymes work, I don't know, but sometimes they do.  I usually advise to enforce a bite after 3 years.  Before this age, they might just be too young to fight the battle yet. They simply don't know how to follow rules until about 3. I have heard of parents turning on the tv so the child mindlessly eats what the parent puts in his mouth. Don't do that! It sets up so many bad eating habits!!!

Until the taste a bite rule can be enforced (and even after that) I like to use hidden foods as nutrients. We are having pumpkin french toast this morning-- pumpkin puree added to the eggs/milk. This is not much vegetable, but more than they would get from a bowl of cereal or standard french toast. If this is done with many meals, it all adds up. Find foods your child likes, then "tweak" to fit in needed nutrients.
Vegetables and fruits can easily be pureed and put into sauces, casseroles, smoothies, and ground meats (meatballs, burgers, meatloaf).  Put a can of beets into the blender with your spaghetti sauce for a funky colored sauce. If your kids don't like sauce on noodles, try making pizza with a zucchini/carrot/beet jazzed up sauce. Some people just finely shred or chop. I find that puree works better because they don't see it and pick it out! There are many recipes for this online and in cookbooks for parents.  Check out my Pinterest Meal Ideas page for starters. (Not all ideas are healthy on this page... some are things I just want to try!)
Putting a cheese sauce over vegetables or offering a dunking sauce (yogurt, catsup, ranch dressing) makes it more acceptable to many kids. 
Add fruits and vegetables to breads or noodles. Most kids love the bread group. Banana bread, pumpkin bread, zucchini bread, spinach noodles, and more are all ways to add a little fruit or vegetable into something they will eat. Yes, they will get more sugar this way, but ...
Try a soup or stew. This is a great time of year to throw things in the crock pot in the morning and come home to the smell of dinner already ready!  
If it's meat he doesn't like (most don't at this age) use other forms of protein and iron (eggs, nuts, legumes, etc). Dairy helps with the protein, but has no iron, so don't only use cheese - a common food they love! You can also try meat hidden in casseroles or in fun forms, but remember there are entire countries of people who don't eat meat. Just make sure your kids are getting the nutrition they need.
Play with the food: make the food fun to eat by arranging into shapes. Use a cookie cutter for fun shapes. Arrange food into a face on the plate. There are many ideas of this online! 
Let kids help prepare the meals in an age/ability safe way, starting with washing vegetables, or arranging them on a plate. Start a garden next season so kids can see the food grow! 
A tip from my mother-in-law: kids will eat anything on a stick or fun appetizer sized! Make roll ups with a tortilla, cream cheese, lunch meats, spinach, or whatever sandwich fillings you use and cut into circles. Put a toothpick in small pieces of fruit or jazzed up meatballs (or load up fruit or vegetables on a skewer for a fun kabob).  

Read books that involve foods. I have put some ideas on my Pinterest Books page. Two of my favorites: "I Will Never Not Ever Eat a Tomato" by Lauren Child and "Green Eggs and Ham" by Dr Seuss. Use the books to stimulate ideas-- like making green eggs!

Above all, try to keep meal time pleasant. It should be a time the family gathers to talk, laugh, and enjoy one another. If the focus is a fight about eating, it is not serving one of the big benefits of eating together.  Work the nutrition in, but keep the meal itself fun!

Post suggestions of what has worked for your family. I always love to hear new tricks!  And if your child is really restricted in foods, talk with your doctor.  Sometimes it's more than just picky!