The best way to prevent travelers’ diarrhea

The best way to prevent travelers’ diarrhea (TD—and not the football kind) is to be prepared with a multipronged approach. For prevention, I recommend packing bismuth subsalicylate (Pepto-Bismol tablets) and a probiotic dietary supplement, such as Lactobacillus rhamnosus GG, and using them daily (I tell you how below). In case you’re unlucky, make sure to have on hand loperamide caplets (Imodium) and the prescription antibiotic rifaximin, which has been FDA approved for travelers’ diarrhea since 2004 (it’s good for both treating and preventing TD).

It’s been called Montezuma’s revenge, the “vacation terminator,” and, um, decorum does not permit me to throw in the other names. Travelers’ diarrhea is the most common travel-related disease in the world: Approximately 40 to 50 percent of people who venture abroad experience an episode of diarrhea. Food and water that have been contaminated with fecal matter are the primary source of the problem.

TD usually occurs within the first week of a trip, and the longer you stay, the lower your chances of getting it (yet another reason to ask for more vacation time). Studies found that individuals who had lived abroad for a year had significantly reduced risk of TD because they had developed an acquired immunity to the microscopic invaders that cause the condition. People raised in an area with a high incidence of TD have a lower risk of getting it in the future, while people raised in more sanitary areas have a higher risk of getting TD when traveling! This adds even more credibility to the hygiene hypothesis: Individuals who were exposed to more diverse infectious sources (animals, other kids, floors, etc.) as kids develop better lifelong immunity than people who were raised in more sterile environments. The relatively germ-free individuals may even experience an exaggerated response to an otherwise mild infection.

The average episode of TD lasts 3 to 5 days! Most cases (50 to 80 percent) are bacterial, so antibiotics could make the difference between having fun on vacation and reading War and Peace in the bathroom. However, viruses and protozoa cause up to one-third of cases. Regardless of the offending bug, the symptoms are pretty much the same: watery diarrhea; fever; nausea; vomiting; abdominal pain/cramps; and even nongastrointestinal complaints, such as joint and muscle pain and headache. Most people get better without serious side effects, but electrolyte deficiency can occur; if symptoms do not improve after 3 days or there is fever or bloody stools, find a doctor. The good news: If you get TD, your chances of contracting it again when traveling within the next year is lower.


Note: Apart from over-the-counter loperamide, which is not officially a supplement (though I consider it one because it’s OTC and originally derived from some natural sources), no dietary supplement should be used to treat TD. The current OTC and prescription treatments are just too good, and in most cases TD resolves on its own. Dietary supplements should be used for prevention of TD. Never use a probiotic if you are immunocompromised or taking prescription immunosuppressive medication, such as the steroid prednisone.

1.Lactobacillus rhamnosus GG probiotic (Culturelle) follow dosage directions on packaging for kids and adults starting 2 days before the trip and daily throughout for prevention

Lactobacillus rhamnosus strain GG can bind to intestinal cells and produce several compounds that fight bad bugs. It’s been on the market longer than any other potentially effective probiotic for TD except Saccharomyces boulardii (see #2), but it has much more favorable research. Two studies with hundreds of travelers found a prevention rate with the GG strain between 12 and 45 percent.

This probiotic usually comes in a powder within a capsule or as a fermented milk product, does not have to be refrigerated, and lasts up to 21 months! (If you can’t figure out how old your product is, just squeeze a capsule. If it’s still soft and flexible, then chances are it’s not expired.) In studies, there were no restrictions on taking the capsules with a meal or on an empty stomach, but the supplement container should be stored in a cool and dark place. (Side note: Probiotics claiming a benefit against TD that have to be refrigerated are a waste of your money. Trying to keep something like this refrigerated when you’re traveling is unrealistic. If it’s that delicate, it probably will not work.) I also like Culturelle because the adult version contains 200 milligrams of inulin, which is a low dose of fiber and a prebiotic, so it increases the chances of healthy bacteria coming into your gastrointestinal tract and promotes regular stool movement. I don’t recommend combining GG with another probiotic supplement for prevention; how this will work is unknown, and more is not always better, even for diarrhea!

2.Saccharomyces boulardii probiotic 1,000 milligrams a day in two divided doses starting 5 days before a trip and daily throughout for prevention

S. boulardii (a yeast-based probiotic) has demonstrated protection in travelers going to North Africa but not to other destinations. Although, the fact that it helped in an area of the world with such a high rate of TD makes me comfortable recommending it for other parts of the globe. Again, the studies do not specify if it should be taken with or without food, so see what works for you.

3. Loperamide up to 16 milligrams a day as needed for treatment only

Loperamide (Imodium) is the most commonly used product for TD, and it’s the most effective OTC treatment. There are very few drugs that can reduce diarrhea after it has started, but loperamide can. Some people consider loperamide to be a drug, but I count it as a supplement because it was potentially derived from a plant and—for all you physiology geeks out there—attaches to receptors in the intestines that normally bind other plantderived products (opiate receptors), so your body thinks it’s a plant, too!

It blocks certain receptors in the intestine to slow the movement of the gastrointestinal tract so that more water can get absorbed, reducing diarrhea. Ask your doctor whether you should take it along with an antibiotic; some say yes, others no. A word of caution about drug interactions: Loperamide is an opioid receptor agonist, so you don’t want to take an opioid, such as codeine, at the same time because it can intensify the sedative side effects and cause a potentially serious drug interaction. (Don’t use it if you have bloody stools or a fever either.) It is safe for kids (see “What Are the Options for Kids?” in this section).

Patients generally take an initial dose of 4 milligrams followed by 2 milligrams every 4 hours with a maximum of 16 milligrams daily. You can take loperamide for about 12 hours after normal stools begin again, but no longer than that; long-term use can alter the functioning of the GI tract. If you have trouble taking pills, liquid loperamide (usually for kids) supplies about 1 milligram of medication for each 7.5 milliliters of the liquid.

The Supplement Handbook - Mark Moyad
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