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).
What is Travelers’ Diarrhea?
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.
Natural Treatment For Treating Travelers’ Diarrhea
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.
What Are Useless For Treating Travelers’ Diarrhea?
I recommend avoiding calcium supplements, such as calcium carbonate, or antacids (including proton pump inhibitors and H2-blockers) while traveling because they can increase the risk of TD. Stomach acid is a critical immune barrier against GI infections, so you don’t want to suppress it.
If you take calcium supplements for osteoporosis, specifically calcium carbonate (the biggest-selling calcium supplements for bone loss in the world), then I suggest taking a break while on your trip. Of course, if you get heart-burn or indigestion while away, then by all means take a TUMS or other antacid, but try to use it only when absolutely needed.
Lactobacillus acidophilus probiotic
This worked as well as or worse than a placebo in a large clinical trial of people who were going to an area with a high rate of TD. (I want to know what they put in the placebo!) Lactobacillus combined with other probiotics hasn’t been shown to be effective either.
These basically feed good bacteria in your gut, keeping them strong and healthy to fight the bad bacteria that find their way in, but the research just isn’t there against TD.
“Immune-boosting” dietary supplements
Whether it’s vitamin C or E or another such supplement (take your pick), they’re all worthless against TD! There’s no evidence they work, and I don’t see researchers ever finding this evidence.
What Are Suitable For Kids to Treat Travelers’ Diarrhea?
TD is more common in kids (probably because their immune systems are still developing), and they’re at higher risk for dehydration and more severe illness. Bismuth subsalicylate (Pepto-Bismol) cannot be used because it’s aspirin-based and can increase the risk of Reye’s syndrome, a potentially deadly problem in kids that has been linked with aspirin use. Some kids older than 2 can use loperamide, but check with your child’s doctor about this as well as antibiotics (some are appropriate for kids while others aren’t). L. rhamnosus GG is an option as well (one capsule a day), but again, talk with your child’s doc. Seek medical attention if your child has a persistent high fever, vomiting, dehydration, or bloody diarrhea.
Pregnant women may be at higher risk for TD because they tend to have lower levels of gastric acid and food takes longer to travel through their GI tracts. Loperamide is safe, but bismuth should be avoided; talk to your doctor.
What Lifestyle Changes Can Help With Travelers’ Diarrhea?
Boil it, cook it, peel it, or forget it
Being vigilant about food and drink while traveling probably only prevents 10 to 20 percent of TD cases, but I think it’s still worth it. Boiling water is the best way to kill all bugs. Don’t get too crazy, though; studies have suggested that people who are completely obsessed with every single thing they eat or drink actually have a higher risk of getting TD (maybe the stress reduces their immune systems). Sorry, all you OCD travelers!
Bring hand sanitizer
Travel with a bottle of ethyl alcohol (62 percent alcohol or higher), and use it to wash your hands before and after every meal when you cannot trust soap and water. When I travel, I also use it to clean suspicious areas, like toilet seats and bike handles.
Bring water purification tablets
You can use potassium iodide, sodium chlorite, or other chlorine water tablets/pellets to treat suspicious water. I prefer potassium because it’s faster, but taste and safety (long term) are an issue. My advice: Add some kind of flavored vitamin C, such as Emergen-C or Ester-C, to improve the taste. The safest option is just to opt for bottled water, though.
If you’re unlucky and get TD, be sure to replace the electrolytes and water you’re losing through diarrhea and vomiting. Sports drinks, coconut water, and even kids’ oral hydration products, such as Pedialyte, contain potassium, sodium, and even chloride and magnesium to get you back to normal again.
Take Pepto daily
Taking two bismuth subsalicylate (Pepto-Bismol) tablets (263 milligrams each) with meals (no more than eight a day)—or drinking 2 ounces of the liquid with meals and once at bedtime—has shown a protection rate against TD of almost 65 percent in preliminary studies. It may be helpful because it coats the GI tract, keeping bugs from taking hold (it also helps reduce bathroom trips once you have TD). The only catch is that in large quantities (more than eight tablets or 10 ounces a day) it can cause a harmless blackening of the stool and tongue, and it could even lead to a mild, temporary case of ringing in the ears.