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INTERNATIONAL MEDICAL INSURANCE AND HEALTH INSURANCE FOR OVERSEAS |
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INTERNATIONAL MEDICAL INSURANCE AND HEALTH INSURANCE FOR OVERSEAS |
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- add to favoritesGLOBAL COVERAGE, INTERNATIONAL HEALTH INSURANCE |
Although international medical insurance is important it is also important to be so prepared in order to avoid health problems overseas.
EXPATRIATE HEALTH
Introduction Nutrition is an area of expatriate health that is under-emphasized, if mentioned at all, to the detriment of many committed individuals who may have wisely planned other aspects of their prospective living or traveling abroad. If nutrition is discussed in traveling or expatriate circles, it’s in the context of food safety, an important but not exclusive concern.
Increasingly, scientific research reveals that nutrition is one of the fundamental factors underlying the development of certain chronic diseases such as adult-onset diabetes, cardiovascular disease, or gastrointestinal inflammatory diseases. There is some evidence that suggests nutrition may also affect mental well-being. Obviously, disease can complicate residing overseas and existing disease could be exacerbated by factors such as stress or unstable food availability. Prevention and management of nutritionally-modifiable chronic disease not only involves maintaining adequacy of essential nutrients, but is also related to weight control. Obesity and overweight, affecting about a third of adults in the U.S., increases the risks of the aforementioned conditions substantially.
Let’s look at the subject of food safety first
Food safety and toxicity The subjects of microbial and environmental contamination, while increasingly drawing attention in this country, take on a more urgent tone when addressing food safety in the developing world. Microbial contamination refers to bacterial or mold infestation; environmental contamination refers to pesticide residue or heavy metals such as lead or aluminum.
Microbial contamination can cause ‘food-borne illness,’ better known as ‘food poisoning’ . Toxins produced by harmful bacteria ingested in food can produce intense and sometimes violent gastrointestinal symptoms. While the primary pathogens are Staphylococcus aureus, Salmonella species and Clostridium perfringens which are responsible for 70 to 80% of all reported outbreaks, there are many other bacterial as well as some viral and protozoan agents. The reported incidence of food-borne illness is increasing worldwide, and in recent years a number of new pathogens have emerged. The World Health Organization’s website, www.who.org , has extensive information on this topic with fact sheets on various pathogens.
It’s wise to be aware of the more likely factors that contribute to food poisoning, particularly in a setting where you may not have total control over food sources, storage, and preparation. The most frequently identified factors that contribute to microbial contamination of food are: improper cooling of food, lapses of 12 or more hours between preparing and eating, improper hygiene of food handlers, and contaminated raw foods. These factors are largely controllable in the States, but perhaps less controllable abroad, depending upon the country of residence.
Control procedures include washing hands before eating and preparing food, sanitizing food preparation surfaces and tools, cooking food to specific temperatures, rapid chilling of food, and storage of food at correct temperatures.
We’re all exposed to an increasing variety and load of toxic substances in the air, water, and in our food. Many developing world environments, however, involve greater exposure to toxins as well as to more noxious agents. Certain foods can be protective because they contain important nutrients that can assist in detoxification or they contain natural antagonists to the toxins. A recent article in the International Journal of Toxicology reviewed the aspects of nutritional protection. For example, vegetables grown in contaminated soil can readily accumulate cadmium, a toxic metal that, at chronic exposure at excessive levels, is associated with kidney problems and possibly neurodegeneration…zinc, contained in a variety of nuts, is a cadmium antagonist and therefore can inhibit its accumulation in the body. Vitamin C, abundant in citrus fruits and brightly colored vegetables, can inhibit the conversion of the meat preservative, sodium nitrite, into carcinogenic substances.
There are many types of toxic agents and examples of protective nutrients that are too numerous to mention here. The point is the importance of doing some basic research about the area where you will be locating to get current and specific information about the environment and food supply so that you can formulate at least a rudimentary plan of health protection that involves diet and may necessarily involve dietary supplementation to attempt to compensate for known risks.
Protection of the intestinal environment For individuals planning to reside in the developing world, it may be important for them to protect their health at the “gut” level. Within the normal healthy intestines is a complex colony of different and mostly beneficial indigenous bacteria called “microflora”…balance within this microbial culture is very important not only to ensure proper digestion and assimilation of dietary nutrients, but also to provide a protective barrier to undigested food and dangerous microbial agents called “antigens”. This is one mechanism whereby immunity is protected, another may be via modulation of immune system mechanisms and defenses.
For centuries, people from all cultures have proclaimed the immune-enhancing benefits of eating fermented foods, particularly yogurt which contains lactic acid bacteria, primarily Lactobacillus acidophilus. Nondairy examples of fermented foods that contain helpful bacteria are sauerkraut and miso. Certain bacterial strains in these foods can survive digestion and reside and proliferate in the gut environment, reducing the toxin-producing “bad” bacteria via various mechanisms, and helping to sustain a balanced microflora.
These bacterial friends can not only be administered in “probiotic” foods, mentioned above, but can be administered in supplement form. According to research, a probiotic is a live microbial culture in a cultured food product. If a dietary probiotic is not available, then a supplement is recommended. An effective probiotic supplement should have specific beneficial microorganisms that are in sufficient numbers and viable to be transplantable in the gut and capable of altering and thus improving the microfloral balance. Administration of probiotics has been found to result in an increase in fecal counts of bifidobacteria and lactobacilli, a decrease in fecal pH, and a decline in those bacterial enzyme activities that are associated with the development of colon cancer.
Research, largely European, specifically Scandinavian and German, has documented various health effects attributed to the use of probiotics including: lower frequency and duration of diarrhea associated with the use of antibiotics, rotavirus infection, chemotherapy, and traveler’s diarrhea; stimulation of both T-cell and B-cell immunity; and, decrease in toxic and carcinogenic substances in the colon. There is some evidence of other benefits such as relief from constipation, as well as irritable bowel and reduction of allergic symptoms possibly by alleviating the intestinal inflammatory response, but further research is needed. Probiotics hold promise as a tool in the treatment of chronic inflammatory diseases that originate in the gut such as gastroenteritis, food allergy, and inflammatory bowel diseases as well as chronic inflammatory disease with a scope beyond the gut, such as rheumatoid arthritis.
Keep in mind that after a course of antibiotics, all bacteria, good and bad, are destroyed; the extent of microflora destruction in the gut depends on the scope of the antibiotic taken. It’s wise to conscientiously ingest fermented foods and/or take a probiotic supplement after finishing the antibiotics to help in quickly restoring a healthy gut environment. Obtain a reputable product that contains strains of bacteria which have been lab-tested to survive intestinal passage such has been found with mostly lactobacilli and bifidobacteria strains, and one that adapts well to the intestinal tract either by adhering to epithelial cells or preventing pathogenic bacteria from adhering.
For example, Lactobacillus plantarum, a species commonly found in the human mucosa and in fermented foods of plant origin, meets those criteria and also seems to counteract groups of adverse bacteria, preventing their adherence to the gut wall. Studies have found that Lactobacillus GG is an effective probiotic strain for treatment of travelers’ diarrhea caused by Escherichia coli. Unless you’re very familiar with this topic, you should check with a knowledgeable health practitioner or pharmacist regarding recommendations for quality supplements.
Chronic disease prevention. A large body of research literature supports the notion that dietary antioxidants play an important role in preventing many human diseases (e.g., cancer, atherosclerosis, stroke, rheumatoid arthritis, neurodegeneration, and diabetes). This prevention is due, in part, to the ability of dietary antioxidants to destroy “free radicals”. Free radicals (e.g., superoxide, nitric oxide, and hydroxyl radicals) and other reactive species (e.g., hydrogen peroxide, peroxynitrite, and hypochlorous acid) are molecules produced in the body as a result of oxidation due to normal aerobic metabolic activities such as breathing, eating, and exercising, as well as through the effects of external factors such as toxicants, pollutants, and radiation. These free radicals result in cascading cell injury and have been implicated in various chronic degenerative processes as well as in the aging process in general.
Dietary antioxidants include various amino acids such as glutathione, vitamins such as vitamin E and vitamin C, and minerals such as selenium and zinc, as well as polyphenols in tea. There are also antioxidant enzymes manufactured in the body such as superoxide dismutase, catalase, glutathione reductase, and glutathione peroxidases. Antioxidants and these antioxidant enzymes work together to scavenge free radicals. There has been growing evidence over the past three decades showing that dietary deficiencies of various nutrients such as protein, selenium, and zinc, or an excess of certain nutrients such as iron, gives rise to cell injury and the oxidation of biomolecules that contributes to chronic degenerative diseases.
Individuals planning to reside in areas of the world that have relatively greater environmental pollution are particularly wise to maintain a high dietary antioxidant intake. Antioxidants are found in varying amounts in fruits and vegetables, particularly those that are brightly-colored and dark green, as well as in green tea. If adequate and consistent produce availability may be in question, a supplemental antioxidant formula is recommended and widely available, but should be purchased in the States.
There is an overwhelming body of literature about this topic on the internet as well as in bookstores which can help, but more often, in terms of sheer volume of information, it can confuse even the most avid nutrition seeker. The most important and fundamental antioxidants to consider in terms of basic supplementation are vitamin C and vitamin E. Vitamin E prevents the oxidation of fats in our bloodstream and sound research has found that it may reduce the risk of heart disease by protecting LDL against oxidation, thereby inhibiting the key factor in the development of atherosclerotic plaque. A protective level of vitamin E exceeds 200 mg/day. A safe and sensible daily recommendation would be somewhere between 200 and 400 mg/day.
Vitamin C has a number of protective roles. Your daily requirement for vitamin C rises when you’re under psychological stress. It also protects tissues from physical (oxidative) stress, such as in infection, extremes in temperatures, toxic metal intake, chronic use of certain medications, as well as protecting iron from oxidation in the gut, thereby enhancing its absorption. Vitamin C scavenges, particularly, the hydroxyl radical and superoxide, thereby helping prevent cancer, heart disease, and cataracts. Vitamin C also acts as a natural antihistamine thereby mitigating the allergic response. A protective level of vitamin C would exceed 600 mg/day. A safe and sensible daily recommendation would be approximately 400-500 mg. a couple times per day.
Medical nutrition therapy is a widely recognized and essential component of treatment for diabetes mellitus, cardiovascular disease, dyslipidemia (unhealthy blood fat and cholesterol levels), and hypertension, all conditions that respond favorably to nutrition. The nutritional focus for these conditions includes reduction of total fat, saturated fat and cholesterol intakes and increasing fruit, vegetable, and fiber consumption. These interventions are intended to normalize lipid levels and other cardiovascular markers, stabilize blood glucose, lower blood pressure and maintain or reduce weight. Substantial evidence suggests that these dietary approaches to disease prevention and treatment are successful, resulting in fewer physician office visits, delay of pharmacotherapy, less frequent hospitalizations and reduced incidence of disease-related complications. Generally, excess diet constituents implicated in disease risk are fats, cholesterol, and sugar, as well as lack of fiber, antioxidants, protein, calcium, iron, vitamin D, and folic acid.
The well known Dietary Approaches to Stop Hypertension (DASH) trial showed that a diet high in fruit, vegetables and fiber and low in fat and cholesterol effectively normalizes blood pressure more than likely resulting from a much higher level of calcium as well as higher potassium and magnesium. Research has found that combined weight loss and dietary intervention are important adjuncts to pharmacotherapy for hypertension. In fact, one study found that weight loss alone results in statistically and clinically significant improvements in blood pressure.
The measures of cardiovascular disease risk are the dietary factors of blood cholesterol levels and homocysteine levels. Three recently published studies from a large randomized trial found that dietary interventions with prepared meal plans led to weight loss, improvements in blood lipid and glucose profiles and reductions in plasma homocysteine and other cardiovascular indicators of risk, diabetes and other chronic conditions. Hundreds of dietary intervention studies support the positions of both the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults and the National Cholesterol Education Program, which recommend nutrition therapy and other lifestyle changes as the initial treatment for unhealthy blood fat and cholesterol levels.
In general, dietary factors that increase blood cholesterol are saturated fat, cholesterol, and trans fatty acids. Trans fatty acids are polyunsaturated fats that have been altered by the hydrogenation process and can damage arterial walls. Dietary factors that decrease blood cholesterol are monounsaturated fat, fish oil, and fiber. Research has also found that low-saturated, high-monounsaturated diets (olive and canola oil) lower total blood cholesterol, specifically the harmful LDL, but tend to increase the beneficial HDL.
Recent research has found that levels of the toxic metabolite, homocysteine, rise to dangerous levels due to inadequate dietary levels of folic acid, vitamin B6, and vitamin B12 and increases the risk of arterial wall damage leading to an increased risk of cardiovascular disease. Low levels of these nutrients, which are found primarily in fresh produce, inhibit the normal conversion of homocysteine to the amino acid, methionine.
General prevention While acute deficiencies of vitamins and minerals are rare in the developed world, we are discovering that suboptimal intake or less than the recommended daily allowance can contribute to the development of chronic disease over time. In the developed world, modern farming, distribution, and storage methods, as well as the modern stressful lifestyle and preference for chemically-processed and fast foods, have all added up to most people, in fact, not consuming optimal daily amounts of all the vitamins and minerals they need from diet alone. Living in the developing world may increase your risk of suboptimal intake of nutrients even more so due to factors such as poverty, lack of infrastructure, etc. Furthermore, as people age, their digestive and absorptive processes are less efficient resulting in lower nutrient assimilation, compounding the risk.
There are a host of chronic daily symptoms beyond the more dramatic ones mentioned above that can be a result of chronically inadequate levels of nutrients…the etiology of symptoms such as headaches, depression, fatigue, and indigestion are often physiological and the source is often dietary. Diet is usually overlooked and these common symptoms are merely medicated. For example, a chronically inadequate intake of one or more of the B vitamins is not unusual, particularly with individuals who eat few fresh vegetables and whole grains. These nutrients are essential for energy metabolism and a low dietary intake can be the causal factor involved in lethargy or fatigue.
The Journal of the American Medical Association has recently stated that it would now be prudent for all adults to take dietary supplements based on the general effectiveness proven in research trials. This advice should certainly be heeded by individuals heading to destinations abroad where dietary and psychological stresses will no doubt abound. But which supplements? A good general guideline is to take a comprehensive multiple vitamin/mineral produced by a reputable company, preferably targeted at your gender and age group. Then, depending upon your destination and with the help of a knowledgeable health practitioner, you may also decide to add a single antioxidant such as vitamin C or an antioxidant formula that can be safely combined with your multiple for added protection.
Being Overweight and obesity No discussion of the health benefits of nutrition is complete without considering the conditions of being overweight and obesity, particularly because they are increasingly prevalent and are associated with a host of chronic diseases, some leading to premature mortality. As we know, both of these conditions, at different levels, are multifactorial and refer to having body fat stores that are excessive for an individual’s height, weight, gender and race to an extent that risks or produces adverse health outcomes such as cardiovascular disease and type 2 diabetes.
A good assessment of how your weight compares to a healthy standard utilizes a calculation of body mass index or BMI…divide your weight (kilograms) by your height (meters) squared. A simple classification of obesity for adults of European origin was developed using the BMI with cutoff points that are based on the extent of risks:
20-24.9 – desirable range
25-29.9 – overweight;
> 30 – obese;
> 40 – very obese.
If you find yourself outside of the desirable range, you would be wise to consider a diet and exercise program with your doctor or health practitioner to prepare yourself physically for relocation. Often, changing a vocation and/or residential location increases psychological stress levels, which exacerbates bad dietary habit. An overweight condition coupled with a higher level of stress can lead to obesity and consequent health problems.
Beyond the weight issue is the importance of the site of the increased fat tissue. Excess abdominal fat is associated with a much higher risk of cardiovascular disease and diabetes even if the BMI is in the desirable range. As such, it may also be important to measure abdominal fat by measuring the waist circumference…greater than 100 cm in men and 95 cm in women indicates increased risk.
Consequences of obesity are many. A cluster of metabolic abnormalities commonly occurs, often described as ‘syndrome X’, whereby levels of LDL cholesterol and triglycerides are high, levels of HDL (protective) are low, levels of insulin are raised yet there is cellular resistance to insulin action, and hypertension prevails. An elevation in liver enzymes due to fatty liver can also be seen which raises the risk of gallstones. Obviously, these factors explain much of the reason that living with excess weight is an important risk factor for cardiovascular disease and the foremost risk factor for diabetes. A higher weight burden on joints is also a consequence leading to osteoarthritis.
Losing weight is an achievable goal when embarking on a sensible eating plan, not a “diet”. Essentially the plan should be characterized by regular meals, no more than 30% of calories from fat, and preferably a shift to monounsaturated fat such as olive oil or canola oil, about 50% of calories from complex carbohydrates such as vegetables, fruits, whole grains, and beans, and about 20% of calories from lean animal protein. The FDA’s Food Guide Pyramid is a visual guide to help meet these recommendations.
Losing weight must also be accompanied by a realistic exercise plan that can be maintained easily in your location and can be as simple and low-intensity as walking 3 times a week for about 30 minutes. Exercise such as this may not produce any major weight losses alone, but will help to change the body composition by increasing muscle tissue and producing a sense of well-being. Help in a total eating and exercise endeavor is available from a myriad of venues, all avowing success and ease, however, the guidelines here and recommendations made throughout this nutrition section are fundamental to any wise plan that will positively affect long-term health.
Nutritional information resources Tufts University maintains a wonderful “Nutrition Navigator” site at www.navigator.tufts.edu that contains extensive and reliable nutritional information for all ages along with links to other nutrition sites. Other sites include:
The American Dietetic Association - www.eatright.org
The World Health Organization - www.who.int
National Institutes of Health – www.nih.gov
U.S. Government health information site – www.healthfinder.gov
Bonnie L. Beezhold, M.H.S., C.C.N.
We invite any inquiries, suggestions, clarifications. We’re here to serve you as part of the Barnabas Team.
Jon and Harriet Askew
(480) 839-6599
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